How To Use CPT Code 52275

CPT 52275 describes a specific procedure involving the inspection and treatment of a urethral stricture in male patients. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 52275?

CPT 52275 is a code used to describe a procedure that involves the inspection and treatment of a urethral stricture in male patients. It is important to note that this code is specifically for male patients, and a different code, CPT 52270, should be used for female patients.

2. Official Description

The official description of CPT code 52275 is: ‘Cystourethroscopy, with internal urethrotomy; male.’

3. Procedure

1. The provider begins by inserting a cystoscope, a lighted tubular instrument, into the male patient’s urethra.
2. Using the cystoscope, the provider inspects the urethra, prostatic urethra, interior of the bladder, and ureteric openings.
3. If a urethral stricture is identified, the provider inserts a specialized instrument called an Otis urethrotome.
4. The provider uses the Otis urethrotome to dilate the stricture and then incise the urethra to widen it and improve urinary flow.
5. Throughout the procedure, the provider may use a camera attached to the cystoscope to view images of the bladder on a monitor.
6. To improve the view of the bladder wall, the provider may inject sterile saline water into the bladder.
7. Once the procedure is complete, the provider removes the instruments and scope and inserts a temporary catheter to allow the urethra to heal.

4. Qualifying circumstances

CPT 52275 is used when a male patient has a urethral stricture that requires inspection and treatment. Urethral strictures can occur due to injury or infection, causing a narrowing of the urethra. This procedure is performed by a provider who is appropriately trained and qualified to perform cystourethroscopy and internal urethrotomy.

5. When to use CPT code 52275

CPT code 52275 should be used when a male patient requires cystourethroscopy with internal urethrotomy to treat a urethral stricture. It is important to note that this code is specific to male patients, and a different code should be used for female patients.

6. Documentation requirements

To support a claim for CPT 52275, the provider must document the following information:

• Patient’s diagnosis of a urethral stricture
• Details of the procedure performed, including the use of a cystoscope and Otis urethrotome
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 52275, ensure that the procedure is performed on a male patient. It is important to use the appropriate code, CPT 52270, for female patients. Additionally, consider any other services or procedures performed during the same encounter and follow the appropriate coding guidelines for reporting multiple procedures.

8. Historical information

CPT 52275 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 urologist performs cystourethroscopy with internal urethrotomy on a male patient with a urethral stricture.
2. A patient presents with urinary flow issues, and a urologist performs cystourethroscopy with internal urethrotomy to treat a urethral stricture.
3. During a routine check-up, a urologist identifies a urethral stricture in a male patient and performs cystourethroscopy with internal urethrotomy to alleviate the narrowing.
4. A patient with a history of urethral stricture undergoes cystourethroscopy with internal urethrotomy to improve urinary flow.
5. A urologist performs cystourethroscopy with internal urethrotomy on a male patient who has been experiencing recurrent urinary tract infections due to a urethral stricture.
6. Following a traumatic injury to the urethra, a urologist performs cystourethroscopy with internal urethrotomy to treat the resulting stricture in a male patient.
7. A patient with a long-standing urethral stricture undergoes cystourethroscopy with internal urethrotomy to alleviate symptoms and improve urinary flow.
8. A urologist performs cystourethroscopy with internal urethrotomy on a male patient with a urethral stricture that has been causing significant discomfort and difficulty with urination.
9. During a diagnostic procedure, a urologist identifies a urethral stricture in a male patient and performs cystourethroscopy with internal urethrotomy to address the issue.
10. A patient with a history of recurrent urinary tract infections undergoes cystourethroscopy with internal urethrotomy to treat a urethral stricture and reduce the risk of future infections.