How To Use CPT Code 51525

CPT 51525 describes a surgical procedure that involves making an incision into the urinary bladder and excising one or more bladder diverticula. 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 51525?

CPT 51525 is a code used to describe a surgical procedure in which the provider makes an incision into the urinary bladder and removes one or more bladder diverticula. Bladder diverticula are herniations or bulges in the bladder wall caused by the protrusion of the lining of the bladder. This procedure is performed to treat bladder diverticula, which can be congenital or acquired.

2. Official Description

The official description of CPT code 51525 is: ‘Cystotomy; for excision of bladder diverticulum, single or multiple (separate procedure).’ This code is used when the provider performs a cystotomy to remove one or more bladder diverticula. It is important to note that this code should not be reported if the procedure is performed along with a related procedure in the same anatomic area or through the same incision, orifice, or surgical approach.

3. Procedure

1. The provider begins by making an incision into the skin of the abdomen overlying the urinary bladder.
2. They then dissect through the subcutaneous tissue or just under the skin and muscles to reach the bladder.
3. After identifying the bladder, the provider checks it by inserting a syringe and draining out the urine.
4. Next, they make an incision into the urinary bladder and locate one or more diverticula.
5. If necessary, a ureteral stent may be placed if the diverticula are close to the ureter.
6. The provider then uses surgical instruments to dissect and excise the diverticulum from the surrounding structures.
7. This procedure is repeated for all diverticula found.
8. After completing the excision, a catheter is placed to drain the urine and prevent leakage from the surgical site.
9. The provider stops any bleeding, inserts a drain, and closes the abdominal wound by suturing the layers of tissue together.
10. The drainage tube and catheter are typically removed after five days.

4. Qualifying circumstances

CPT 51525 is performed on patients with bladder diverticula, which are herniations or bulges in the bladder wall. These diverticula can be congenital or acquired. The procedure is typically performed by a provider who is appropriately trained and qualified to perform cystotomy procedures. It is important to note that this code should not be reported if the procedure is performed along with a related procedure in the same anatomic area or through the same incision, orifice, or surgical approach.

5. When to use CPT code 51525

CPT code 51525 should be used when the provider performs a cystotomy to excise one or more bladder diverticula. It is important to ensure that the procedure is not performed along with a related procedure in the same anatomic area or through the same incision, orifice, or surgical approach. If the procedure is performed with an unrelated procedure, modifier 59, Distinct procedural service, should be appended to the code to indicate that it is a separate procedure.

6. Documentation requirements

To support a claim for CPT 51525, the provider must document the following information:

• Patient’s diagnosis of bladder diverticula
• Description of the procedure performed, including the number of diverticula excised
• Date of the procedure
• Details of the surgical approach and any additional procedures performed
• Any complications or unexpected findings
• Post-operative care instructions
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 51525, ensure that the procedure is not performed along with a related procedure in the same anatomic area or through the same incision, orifice, or surgical approach. If the procedure is performed with an unrelated procedure, modifier 59 should be appended to indicate that it is a separate procedure. It is important to review the documentation and ensure that it supports the use of the modifier. Modifier 51 should not be used with CPT 51525, as it is not a multiple procedure code.

8. Historical information

CPT 51525 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. It is important to stay updated with any changes or revisions to the code in future editions of the CPT manual.

9. Examples

1. A provider performs CPT 51525 to excise a bladder diverticulum in a patient with a congenital bladder abnormality.
2. During a surgical procedure, the provider identifies and removes multiple bladder diverticula using CPT 51525.
3. A patient presents with acquired bladder diverticula, and the provider performs CPT 51525 to excise the diverticula and repair the bladder.
4. A provider performs CPT 51525 to remove a large bladder diverticulum that is causing urinary symptoms in a patient.
5. During a cystotomy procedure, the provider identifies and excises multiple bladder diverticula using CPT 51525.
6. A patient with recurrent bladder diverticula undergoes CPT 51525 to remove the diverticula and improve their urinary function.
7. A provider performs CPT 51525 to excise a bladder diverticulum that is causing recurrent urinary tract infections in a patient.
8. During a surgical procedure, the provider identifies and removes a single bladder diverticulum using CPT 51525.