How To Use CPT Code 52265

CPT 52265 describes the procedure of cystourethroscopy with dilation of the bladder for interstitial cystitis under local anesthesia. 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 52265?

CPT 52265 can be used to describe the cystourethroscopy procedure with dilation of the bladder for interstitial cystitis. This procedure is performed under local anesthesia and involves the inspection of the urethra, prostatic urethra (in men), the interior of the bladder, and ureteric openings using a cystoscope passed through the urethra and into the bladder.

2. Official Description

The official description of CPT code 52265 is: ‘Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia.’

3. Procedure

1. The provider administers local anesthesia to the urethra.
2. The provider inserts a cystoscope into the urethra and slowly glides it up and into the bladder.
3. The provider inspects the urethra, prostatic urethra (in men), the interior of the bladder, and ureteric openings using the camera attached to the cystoscope.
4. The provider injects sterile saline water into the bladder to dilate it and improve the view of the bladder wall.
5. The provider may instill a combination of medications, such as lidocaine, sodium bicarbonate, and pentosan, to reduce bladder irritation and treat the interstitial cystitis.
6. If necessary, the provider may repeat the treatment if the condition fails to improve.
7. The provider drains the bladder and removes the instruments.

4. Qualifying circumstances

CPT 52265 is performed on patients with interstitial cystitis, a chronic, painful bladder inflammation not associated with infection. The procedure is done under local anesthesia and requires the use of a cystoscope to inspect the bladder. Medications may be instilled to reduce bladder irritation and treat the condition.

5. When to use CPT code 52265

CPT code 52265 should be used when performing cystourethroscopy with dilation of the bladder for interstitial cystitis under local anesthesia. It should not be used if the patient received general or spinal anesthesia. Other codes should be used for similar procedures performed under different types of anesthesia.

6. Documentation requirements

To support a claim for CPT 52265, the provider must document the following information:

• Patient’s diagnosis of interstitial cystitis
• Use of local anesthesia
• Date of the procedure
• Specific details of the procedure, including the use of a cystoscope and bladder dilation
• Medications instilled, if applicable
• Any complications or additional treatments performed
• Provider’s signature

7. Billing guidelines

When billing for CPT 52265, ensure that the procedure was performed under local anesthesia. Do not report this code if the patient received general or spinal anesthesia. It is important to use the appropriate anesthesia code if a different type of anesthesia was used. Follow the specific guidelines provided by the payer for accurate billing.

8. Historical information

CPT 52265 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 urologist performs cystourethroscopy with bladder dilation under local anesthesia for a patient with interstitial cystitis.
2. A female patient with interstitial cystitis undergoes cystourethroscopy with bladder dilation under local anesthesia to assess the condition of her bladder.
3. A urologist uses cystourethroscopy with bladder dilation under local anesthesia to treat a male patient with interstitial cystitis.
4. A patient with interstitial cystitis receives cystourethroscopy with bladder dilation under local anesthesia as part of their ongoing treatment plan.
5. A urologist performs cystourethroscopy with bladder dilation under local anesthesia to evaluate the effectiveness of previous treatments for a patient with interstitial cystitis.
6. A female patient with interstitial cystitis undergoes cystourethroscopy with bladder dilation under local anesthesia to alleviate her symptoms.
7. A urologist uses cystourethroscopy with bladder dilation under local anesthesia to monitor the progression of interstitial cystitis in a male patient.
8. A patient with interstitial cystitis receives cystourethroscopy with bladder dilation under local anesthesia to improve their quality of life.
9. A urologist performs cystourethroscopy with bladder dilation under local anesthesia to assess the severity of interstitial cystitis in a female patient.
10. A male patient with interstitial cystitis undergoes cystourethroscopy with bladder dilation under local anesthesia to determine the appropriate treatment plan.