How To Use CPT Code 51060

CPT 51060 describes the procedure of transvesical ureterolithotomy, which involves the removal of a stone from the ureter through an incision made in the urinary bladder. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 51060?

CPT 51060 is used to describe the surgical procedure known as transvesical ureterolithotomy. This procedure involves making an incision in the urinary bladder and ureter to remove a stone from the ureter. The provider may also perform resection of the bladder neck during this procedure.

2. Official Description

The official description of CPT code 51060 is: ‘Transvesical ureterolithotomy; with resection of bladder neck.’

3. Procedure

1. The provider begins by making an incision in the skin of the abdomen overlying the urinary bladder and ureters.
2. They then dissect through the subcutaneous tissue or just under the skin and muscles to reach the bladder and ureters.
3. The provider checks the bladder by inserting a syringe and draining out the urine.
4. Next, they make an incision in the urinary bladder wall and the ureter, depending on the size of the stone.
5. The stone, along with the bladder neck, is then removed using forceps or a grasping device.
6. The provider sutures the bladder incision and places a catheter to drain the urine and prevent leakage from the surgical site.
7. Finally, they stop any bleeding, insert a drain, and close the abdominal wound by suturing the layers of tissue together. The drainage tube and catheter are typically removed after five days.

4. Qualifying circumstances

CPT 51060 is performed on patients who require the surgical removal of a stone from the ureter. The procedure may also involve resection of the bladder neck. It is important to note that this procedure is only performed when other methods of stone removal have been deemed ineffective or inappropriate.

5. When to use CPT code 51060

CPT code 51060 should be used when the provider performs a transvesical ureterolithotomy with resection of the bladder neck. It is important to ensure that this procedure is medically necessary and appropriate for the patient’s condition. Other methods of stone removal should be considered and attempted before resorting to this surgical procedure.

6. Documentation requirements

To support a claim for CPT 51060, the provider must document the following information:

• Patient’s diagnosis and the need for transvesical ureterolithotomy
• Details of the procedure, including the incision made in the urinary bladder and ureter, as well as the resection of the bladder neck
• Date of the procedure
• Any complications or unexpected findings during the procedure
• Post-operative care instructions and follow-up plans
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 51060, it is important to ensure that the procedure performed matches the description of the code. The provider should also ensure that the documentation supports the medical necessity of the procedure. It is important to follow any specific billing guidelines provided by the payer or Medicare to ensure accurate reimbursement.

8. Historical information

CPT 51060 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with a large ureteral stone undergoes transvesical ureterolithotomy with resection of the bladder neck to remove the stone.
2. A provider performs transvesical ureterolithotomy with resection of the bladder neck on a patient with recurrent ureteral stones.
3. A patient with a complex ureteral stone requires transvesical ureterolithotomy with resection of the bladder neck for stone removal.
4. A provider performs transvesical ureterolithotomy with resection of the bladder neck on a patient with a large impacted ureteral stone.
5. A patient with a history of bladder neck obstruction undergoes transvesical ureterolithotomy with resection of the bladder neck for stone removal.
6. A provider performs transvesical ureterolithotomy with resection of the bladder neck on a patient with a ureteral stone causing severe pain and obstruction.
7. A patient with a recurrent ureteral stone and bladder neck dysfunction undergoes transvesical ureterolithotomy with resection of the bladder neck.
8. A provider performs transvesical ureterolithotomy with resection of the bladder neck on a patient with a large ureteral stone causing urinary tract infections.
9. A patient with a complex ureteral stone and bladder neck obstruction requires transvesical ureterolithotomy with resection of the bladder neck for stone removal.
10. A provider performs transvesical ureterolithotomy with resection of the bladder neck on a patient with a large impacted ureteral stone causing severe pain and urinary obstruction.