How To Use CPT Code 51535

CPT 51535 describes a specific procedure for the excision, incision, or repair of an ureterocele, which is an abnormal dilation in the ureter where it inserts into 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 51535?

CPT 51535 is a code used to describe a surgical procedure that involves making an incision into the urinary bladder and excising, incising, or repairing an ureterocele. An ureterocele is a congenital anomaly characterized by an abnormal dilation in the ureter where it inserts into the urinary bladder. This procedure aims to normalize the urine flow and address any defects in the ureter.

2. Official Description

The official description of CPT code 51535 is: ‘Cystotomy for excision, incision, or repair of ureterocele.’

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 access the bladder.
3. The provider checks the bladder by inserting a syringe and draining out the urine.
4. Above the bladder, they identify the ureters, which are dilated at their entry into the bladder.
5. The provider then incises, excises, or repairs the abnormal dilation in the ureters by making an incision into the bladder to access the opening and normalize the urine flow.
6. They inspect the ureter for any other defects and repair the bladder incision.
7. A ureteral catheter is placed to drain the urine and prevent leakage from the surgical site.
8. The provider ensures there is no bleeding, places a drain, and closes the abdominal wound by suturing the layers of tissue together.
9. The drainage tube and catheter are typically removed after five days.

4. Qualifying circumstances

CPT 51535 is performed on patients with ureterocele, a congenital abnormality in the ureter. The procedure is indicated when there is a need to excise, incise, or repair the ureterocele to normalize urine flow. It is important to note that for a bilateral procedure, modifier 50 should be appended to the code. For transurethral excision, a different code, 52300, should be used.

5. When to use CPT code 51535

CPT code 51535 should be used when a provider performs a cystotomy for the excision, incision, or repair of an ureterocele. It is important to ensure that the procedure aligns with the specific requirements outlined in the code description.

6. Documentation requirements

To support a claim for CPT 51535, the provider must document the following information:

• Patient’s diagnosis of ureterocele
• Details of the procedure performed (excision, incision, or repair)
• Date of the procedure
• Start and end time of the procedure
• Any additional findings or defects in the ureter
• Placement of a ureteral catheter
• Details of any complications or post-operative care
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 51535, ensure that the procedure meets the specific requirements outlined in the code description. It is important to append modifier 50 for a bilateral procedure. Additionally, if a transurethral excision is performed instead, a different code, 52300, should be used. Take note of any specific guidelines provided by the payer or coding guidelines to ensure accurate billing.

8. Historical information

CPT 51535 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A provider performs a cystotomy to excise an ureterocele in a patient with a congenital abnormality.
2. During a surgical procedure, a provider makes an incision into the bladder to repair an ureterocele in a patient with urine flow abnormalities.
3. A patient undergoes cystotomy for the incision and repair of an ureterocele to normalize urine flow.
4. A provider performs a cystotomy to excise an ureterocele and repair any defects in the ureter in a patient with recurrent urinary tract infections.
5. During a surgical procedure, a provider makes an incision into the bladder to repair an ureterocele and improve urine flow in a patient with hydronephrosis.
6. A patient undergoes cystotomy for the excision of an ureterocele and subsequent repair of the bladder in a case of urinary obstruction.
7. A provider performs a cystotomy to repair an ureterocele and address any associated complications in a patient with recurrent kidney stones.
8. During a surgical procedure, a provider makes an incision into the bladder to excise an ureterocele and improve urine flow in a patient with urinary incontinence.
9. A patient undergoes cystotomy for the repair of an ureterocele and correction of urine flow abnormalities in a case of vesicoureteral reflux.
10. A provider performs a cystotomy to excise an ureterocele and repair any defects in the ureter in a patient with chronic kidney disease.