How To Use CPT Code 52300

CPT 52300 describes the resection or fulguration of orthotopic ureterocele(s) using cystourethroscopy. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 52300?

CPT 52300 is used to describe a surgical procedure that involves the resection or fulguration of orthotopic ureterocele(s) using cystourethroscopy. This code is used when a physician inserts a cystoscope into the urethra and bladder to inspect the urethra, prostatic urethra (in men), and the interior of the bladder. During the procedure, the physician identifies and treats orthotopic ureteroceles by either cutting them out (resection) or destroying them with high-frequency electric current (fulguration).

2. Official Description

The official description of CPT code 52300 is: ‘Cystourethroscopy; with resection or fulguration of orthotopic ureterocele(s), unilateral or bilateral.’

3. Procedure

1. Under anesthesia, the physician inserts a cystoscope into the urethra and slowly advances it into the bladder.
2. The physician examines the urethra, prostatic urethra (in men), and the interior of the bladder using the camera attached to the cystoscope.
3. To improve the view of the bladder wall, the physician injects sterile saline water into the bladder.
4. During the examination, the physician identifies orthotopic ureteroceles, which are saclike protrusions of the ureteral meatus into the bladder.
5. The physician performs either resection or fulguration of the orthotopic ureteroceles using appropriate instruments.
6. If both ureteroceles are present, the physician performs bilateral resection or fulguration.
7. The physician inspects the area for any bleeding and controls it if necessary.
8. After completing the procedure, the physician drains the bladder and removes the cystoscope and any other instruments.

4. Qualifying circumstances

CPT 52300 is performed on patients with orthotopic ureteroceles, which are saclike protrusions of the ureteral meatus into the bladder. The procedure is typically done when the ureteroceles cause symptoms or complications, such as urinary obstruction or recurrent urinary tract infections. It is important to note that this code is specific to orthotopic ureteroceles and should not be used for ectopic ureteroceles, which are ureters that terminate at a different site.

5. When to use CPT code 52300

CPT code 52300 should be used when a physician performs the resection or fulguration of orthotopic ureteroceles using cystourethroscopy. It is important to ensure that the procedure is performed on orthotopic ureteroceles and not ectopic ureteroceles. This code can be used for both unilateral and bilateral procedures, and there is no need to append modifier 50.

6. Documentation requirements

To support a claim for CPT 52300, the physician must document the following information:

• Patient’s diagnosis of orthotopic ureteroceles
• Details of the procedure performed, including whether resection or fulguration was done
• Laterality (unilateral or bilateral)
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the performing physician

7. Billing guidelines

When billing for CPT 52300, ensure that the procedure involves the resection or fulguration of orthotopic ureteroceles using cystourethroscopy. It is important to accurately document the laterality (unilateral or bilateral) of the procedure. Modifier 50 should not be appended to this code. Additionally, it is important to note that CPT code 52300 should not be reported with other codes for the same procedure on ectopic ureteroceles.

8. Historical information

CPT code 52300 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 physician performing the resection of a unilateral orthotopic ureterocele using cystourethroscopy.
2. A urologist fulgurating bilateral orthotopic ureteroceles during a cystourethroscopy procedure.
3. A surgeon resecting a large orthotopic ureterocele in a pediatric patient using cystourethroscopy.
4. An interventional radiologist performing the fulguration of an orthotopic ureterocele in an adult patient with recurrent urinary tract infections.
5. A urogynecologist resecting a unilateral orthotopic ureterocele and repairing the ureteral opening during a cystourethroscopy procedure.
6. A pediatric urologist fulgurating bilateral orthotopic ureteroceles in an infant using cystourethroscopy.
7. A urological surgeon resecting a recurrent orthotopic ureterocele in a patient with a history of urinary obstruction.
8. An interventional radiologist fulgurating a large orthotopic ureterocele in a patient with urinary incontinence.
9. A urogynecologist resecting a unilateral orthotopic ureterocele and performing a bladder neck suspension during a cystourethroscopy procedure.
10. A urologist fulgurating bilateral orthotopic ureteroceles in a patient with chronic kidney disease.