How To Use CPT Code 52315

CPT 52315 describes the removal of a foreign body, calculus, or ureteral stent from the urethra or bladder 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 52315?

CPT 52315 is used to describe the removal of a foreign body, calculus, or ureteral stent from the urethra or bladder using cystourethroscopy. This procedure involves the insertion of a cystoscope through the urethra and into the bladder to inspect and remove the object or stent. It may require additional time and effort due to complications such as excessive bleeding, inadvertent tear of the ureter, stricture, or other complexities.

2. Official Description

The official description of CPT code 52315 is: ‘Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); complicated.’

3. Procedure

1. The provider begins by inserting a cystoscope into the urethra and slowly advancing it into the bladder.
2. The cystoscope is equipped with a camera that allows the provider to visualize the interior of the bladder on a monitor.
3. The provider examines the urethra and injects sterile saline water into the bladder to enhance the view of the bladder wall.
4. If a foreign body, calculus, or displaced ureteral stent is identified, the provider uses specialized grasping forceps inserted through the cystoscope to remove the object or stent.
5. During the procedure, the provider may encounter complications such as a stricture or challenging positioning of the object, which may require additional time and effort.
6. If there is an inadvertent tear of the bladder wall or urethra or excessive bleeding, the provider will need to control and repair the damage, further complicating the procedure.
7. After thorough inspection and irrigation of the bladder, the provider drains the bladder and removes the cystoscope and instruments.

4. Qualifying circumstances

CPT 52315 is performed in cases where the cystourethroscopy procedure becomes complicated due to excessive bleeding, inadvertent tear of the ureter, stricture, or other complications. The presence of a foreign body, calculus, or displaced ureteral stent in the urethra or bladder necessitates the use of this code. The procedure is typically carried out by a urologist or other qualified healthcare professional.

5. When to use CPT code 52315

CPT code 52315 should be used when a complicated cystourethroscopy is performed to remove a foreign body, calculus, or ureteral stent from the urethra or bladder. It should not be reported when performed along with a related procedure in the same anatomic area or through the same incision, orifice, or surgical approach. If the procedure is performed with an unrelated procedure, modifier 59, Distinct procedural service, should be appended to the code.

6. Documentation requirements

To support a claim for CPT 52315, the provider must document the following information:

• Reason for the procedure and the presence of a foreign body, calculus, or ureteral stent
• Details of the cystourethroscopy procedure, including the use of a cystoscope and any complications encountered
• Description of the object or stent removed
• Any additional time or effort required due to complications
• Repair or control of any inadvertent tears or excessive bleeding
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 52315, ensure that the procedure meets the criteria for a complicated cystourethroscopy with the removal of a foreign body, calculus, or ureteral stent. It should not be reported when performed with a related procedure in the same anatomic area or through the same incision, orifice, or surgical approach. If performed with an unrelated procedure, modifier 59 should be appended to the code to indicate a distinct procedural service.

8. Historical information

CPT 52315 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 a complicated cystourethroscopy to remove a foreign body from the bladder of a patient who accidentally inserted a small object.
2. A patient presents with a ureteral stent that has become displaced and lodged in the bladder. The urologist performs a cystourethroscopy to remove the stent, encountering complications due to the stent’s position.
3. A calculus is discovered in the urethra of a patient during a cystourethroscopy. The urologist successfully removes the calculus, but the procedure becomes complicated due to excessive bleeding.
4. A patient with a history of urethral stricture requires a cystourethroscopy to remove a foreign body. The urologist encounters challenges due to the stricture, requiring additional time and effort.
5. A urologist performs a cystourethroscopy to remove a displaced ureteral stent from the bladder of a patient who had undergone a previous surgical procedure. The procedure becomes complicated due to an inadvertent tear of the ureter.