How To Use CPT Code 52234

CPT 52234 describes a specific procedure for cystourethroscopy, involving the inspection and treatment of small bladder tumors. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 52234?

CPT 52234 is a code used to describe a cystourethroscopy procedure that involves the inspection and treatment of small bladder tumors. This procedure is performed using a cystoscope, which is a lighted tubular instrument that is inserted through the urethra and into the bladder. The provider uses specialized instruments to destroy small lesions between 0.5 cm and 2.0 cm in size, using high-intensity electric current, cryosurgery, or laser surgery.

2. Official Description

The official description of CPT code 52234 is: ‘Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)’. This code specifically refers to the inspection and treatment of small bladder tumors using various techniques such as fulguration, cryosurgery, or laser surgery.

3. Procedure

1. The provider begins by inserting a cystoscope into the urethra and slowly gliding it up into the bladder.
2. Using the camera attached to the cystoscope, the provider inspects the urethra, prostatic urethra (in men), the interior of the bladder, and ureteric openings.
3. To improve the view of the bladder wall, the provider injects sterile saline water into the bladder.
4. The provider identifies small bladder tumors between 0.5 cm and 2.0 cm in size.
5. Using specialized instruments, the provider performs fulguration, cryosurgery, or laser surgery to destroy the small lesions.
6. Upon completion of the procedure, the provider removes the instruments and drains the bladder.

4. Qualifying circumstances

CPT 52234 is used for patients with small bladder tumors between 0.5 cm and 2.0 cm in size. The procedure is typically performed by a healthcare professional who is experienced in cystourethroscopy and has the necessary equipment and instruments to perform fulguration, cryosurgery, or laser surgery. The patient must be appropriately prepped and anesthetized, which may involve instilling anesthetizing gel into the urethra and/or sedating the patient.

5. When to use CPT code 52234

CPT code 52234 should be used when a healthcare professional performs cystourethroscopy to inspect and treat small bladder tumors between 0.5 cm and 2.0 cm in size. This code is specific to the procedure described and should not be used for other bladder or urethral conditions or treatments.

6. Documentation requirements

To support a claim for CPT 52234, the healthcare professional must document the following information:

• Patient’s diagnosis and the presence of small bladder tumors
• Details of the procedure performed, including the use of fulguration, cryosurgery, or laser surgery
• Size of the bladder tumors
• Date and duration of the procedure
• Any complications or additional treatments performed
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 52234, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the size of the bladder tumors and the specific techniques used for treatment. CPT code 52234 should not be reported with other codes unless additional procedures or treatments are performed during the same session.

8. Historical information

CPT 52234 was added to the Current Procedural Terminology system on January 1, 1990. There was a code change on January 1, 2005, which modified the description of the procedure to include the specific size range of small bladder tumors.

9. Examples

1. A healthcare professional performs cystourethroscopy on a patient with a small bladder tumor measuring 1.5 cm in size. The provider uses fulguration to destroy the tumor during the procedure.
2. During a cystourethroscopy procedure, a provider identifies a small bladder tumor measuring 0.8 cm in size. The tumor is treated using cryosurgery to freeze and destroy the abnormal tissue.
3. A patient undergoes cystourethroscopy for the inspection and treatment of a small bladder tumor measuring 1.2 cm in size. The provider uses laser surgery to remove the tumor during the procedure.
4. During a cystourethroscopy procedure, a healthcare professional identifies multiple small bladder tumors ranging from 0.5 cm to 1.5 cm in size. The provider performs fulguration to destroy all the tumors.
5. A patient with a small bladder tumor measuring 1.7 cm in size undergoes cystourethroscopy. The provider uses a combination of cryosurgery and fulguration to treat the tumor during the procedure.
6. During a cystourethroscopy procedure, a healthcare professional identifies a small bladder tumor measuring 0.6 cm in size. The tumor is treated using laser surgery to remove the abnormal tissue.