How To Use CPT Code 52276

CPT 52276 describes a specific procedure known as cystourethroscopy with direct vision internal urethrotomy. 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 52276?

CPT 52276 is used to describe a procedure called cystourethroscopy with direct vision internal urethrotomy. This procedure involves the use of a cystoscope, a lighted tubular instrument, to inspect the urethra, the interior of the bladder, and the ureteric openings. The provider then incises a narrowed area, known as a stricture, in the internal urethra under direct vision.

2. Official Description

The official description of CPT code 52276 is: ‘Cystourethroscopy, with direct vision internal urethrotomy.’

3. Procedure

1. The patient is appropriately prepped and placed under general or spinal anesthesia.
2. The provider inserts a cystoscope into the urethra and advances it into the bladder.
3. Upon encountering a stricture, the provider removes the cystoscope and inserts a dilator into the urethra to expand the narrowed area.
4. Under direct vision, the provider then inserts a specially designed cutting instrument called a cold knife and incises the strictured area down to healthy tissues.
5. The provider reinserts the cystoscope and examines the bladder, injecting sterile saline water to improve the view of the bladder wall.
6. Once the examination is complete, the provider empties the bladder, irrigates the urethra, and removes the instruments and scope.
7. A temporary catheter is inserted through the urethra and into the bladder to allow the incised area in the urethra to heal.

4. Qualifying circumstances

CPT 52276 is performed on patients with strictures in the urethra. Strictures can occur due to injury or infection and result in a narrowing of the urethra. This procedure is typically performed by a provider who is experienced in cystourethroscopy and has the necessary equipment and instruments to perform the internal urethrotomy.

5. When to use CPT code 52276

CPT code 52276 should be used when a provider performs a cystourethroscopy with direct vision internal urethrotomy. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the procedure does not involve direct vision internal urethrotomy, a different code should be used.

6. Documentation requirements

To support a claim for CPT 52276, the provider must document the following information:

• Patient’s medical history and the presence of a urethral stricture
• Details of the procedure, including the use of a cystoscope, dilator, and cold knife
• Date and duration of the procedure
• Findings during the cystourethroscopy, including any complications or additional procedures performed
• Use of anesthesia and any medications administered
• Post-procedure care, including the insertion of a temporary catheter
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 52276, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the details of the procedure and provide any necessary supporting documentation. CPT code 52276 should not be reported with other codes that describe different procedures or services. It is important to review the documentation guidelines and requirements of the specific payer to ensure proper billing and reimbursement.

8. Historical information

CPT 52276 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 patient undergoes cystourethroscopy with direct vision internal urethrotomy to treat a urethral stricture.
2. A provider performs cystourethroscopy with direct vision internal urethrotomy on a patient with recurrent bladder neck contracture.
3. A patient with a history of urethral stricture undergoes cystourethroscopy with direct vision internal urethrotomy to relieve urinary obstruction.
4. A provider performs cystourethroscopy with direct vision internal urethrotomy on a patient with a bladder tumor and a concurrent urethral stricture.
5. A patient with a history of urethral stricture undergoes cystourethroscopy with direct vision internal urethrotomy to improve urinary flow.
6. A provider performs cystourethroscopy with direct vision internal urethrotomy on a patient with a urethral stricture caused by previous radiation therapy.
7. A patient undergoes cystourethroscopy with direct vision internal urethrotomy to treat a recurrent urethral stricture.
8. A provider performs cystourethroscopy with direct vision internal urethrotomy on a patient with a urethral stricture and bladder stones.
9. A patient with a history of urethral stricture undergoes cystourethroscopy with direct vision internal urethrotomy to alleviate urinary symptoms.
10. A provider performs cystourethroscopy with direct vision internal urethrotomy on a patient with a urethral stricture and recurrent urinary tract infections.