How To Use CPT Code 52301

CPT 52301 describes the resection or fulguration of ectopic 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 52301?

CPT 52301 can be used to describe a surgical procedure that involves the resection or fulguration of ectopic ureterocele(s) using cystourethroscopy. This code is used when a healthcare provider inspects the urethra, prostatic urethra (in men), the interior of the bladder, and ureteric openings using a cystoscope. The provider then cuts out or destroys an abnormally placed ureterocele on one or both sides.

2. Official Description

The official description of CPT code 52301 is: ‘Cystourethroscopy; with resection or fulguration of ectopic ureterocele(s), unilateral or bilateral.’

3. Procedure

1. The healthcare provider inserts a cystoscope into the urethra and slowly moves it up into the bladder.
2. The provider examines the urethra and injects sterile saline water into the bladder to improve the view of the bladder wall.
3. During the examination, the provider identifies an ectopic ureterocele, which is a saclike protrusion of the ureteral meatus into the bladder.
4. The provider then resects (cuts out) or fulgurates (destroys with high-frequency electric current) the ureterocele.
5. If both ureters are affected, the provider may perform a bilateral resection or fulguration of the ureterocele.
6. The provider inspects the area and controls any bleeding.
7. Once the procedure is completed, the provider drains the bladder and removes the cystoscope and any other instruments.

4. Qualifying circumstances

CPT 52301 is performed on patients with ectopic ureteroceles, which are saclike protrusions of the ureteral meatus into the bladder. The procedure is typically done under anesthesia and requires the use of a cystoscope to visualize and treat the ureterocele. It can be performed unilaterally or bilaterally, depending on the patient’s condition.

5. When to use CPT code 52301

CPT code 52301 should be used when a healthcare provider performs the resection or fulguration of ectopic ureterocele(s) using cystourethroscopy. This code is appropriate for both unilateral and bilateral procedures. It should not be reported for normally placed (orthotopic) ureterocele procedures, which have a separate CPT code (52300).

6. Documentation requirements

To support a claim for CPT 52301, the healthcare provider must document the following information:

• Patient’s diagnosis of ectopic ureterocele(s)
• Details of the procedure performed, including whether resection or fulguration was done
• Whether the procedure was unilateral or bilateral
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 52301, ensure that the procedure involves the resection or fulguration of ectopic ureterocele(s) using cystourethroscopy. Use the appropriate CPT code based on whether the procedure is unilateral or bilateral. There is no need to append modifier 50 for bilateral procedures. It is important to note that CPT code 52301 should not be reported with other codes such as CPT codes 52300. Additional tips for reporting CPT code 52301 may include considering the location of the testing and the need for anesthesia.

8. Historical information

CPT 52301 was added to the Current Procedural Terminology system on January 1, 1997. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider performs cystourethroscopy and resects an ectopic ureterocele on one side for a patient with a diagnosed condition.
2. Using cystourethroscopy, a healthcare provider fulgurates bilateral ectopic ureteroceles for a patient with a known medical condition.
3. A patient undergoes cystourethroscopy, and the healthcare provider resects an ectopic ureterocele on one side and fulgurates the other side.
4. During a cystourethroscopy procedure, a healthcare provider resects multiple ectopic ureteroceles on one side for a patient with a complex medical history.
5. A healthcare provider performs cystourethroscopy and resects a large ectopic ureterocele on one side, requiring additional time and expertise.
6. Using cystourethroscopy, a healthcare provider fulgurates bilateral ectopic ureteroceles for a pediatric patient with a congenital condition.
7. A patient with recurrent urinary tract infections undergoes cystourethroscopy, and the healthcare provider resects an ectopic ureterocele on one side to improve urinary flow.
8. During a cystourethroscopy procedure, a healthcare provider resects an ectopic ureterocele on one side and discovers a second smaller ureterocele that requires fulguration.
9. A healthcare provider performs cystourethroscopy and resects an ectopic ureterocele on one side, which had been causing recurrent bladder infections for the patient.