How To Use CPT Code 52345

CPT 52345 describes a specific procedure known as cystourethroscopy with ureteroscopy, which involves the inspection and treatment of a ureteropelvic junction stricture. This article will provide an overview of the code, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 52345?

CPT 52345 is a code used to describe a procedure called cystourethroscopy with ureteroscopy, specifically for the treatment of a ureteropelvic junction stricture. This procedure involves the use of a cystoscope, which is a flexible or rigid tube with a camera, to inspect the bladder, urethra, prostatic urethra, and ureteric openings. The provider then passes a ureteroscope up to the ureteropelvic junction, where various treatment methods can be employed to address the stricture.

2. Official Description

The official description of CPT code 52345 is: ‘Cystourethroscopy with ureteroscopy; with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, electrocautery, and incision).’ This code specifically refers to the inspection and treatment of a ureteropelvic junction stricture using cystourethroscopy and ureteroscopy.

3. Procedure

1. During the procedure, the provider inserts a cystoscope into the urethra and slowly advances it into the bladder. This allows for the inspection of the bladder, urethra, prostatic urethra, and ureteric openings.
2. The provider may inject sterile saline water into the bladder to enhance the view of the bladder wall.
3. A ureteroscope is then advanced into the ureters to reach the ureteropelvic junction.
4. If a stricture is identified at the ureteropelvic junction, the provider can choose from various treatment methods, such as balloon dilation, laser therapy, electrocautery, or incision, to address the stricture and increase the diameter of the ureter.
5. Once the treatment is complete, the provider removes the scope and any other instruments used during the procedure.
6. The bladder is drained to complete the procedure.

4. Qualifying circumstances

CPT 52345 is used when a patient presents with a ureteropelvic junction stricture that requires treatment. This procedure is typically performed under anesthesia. The provider must use a cystoscope and a ureteroscope to inspect and treat the stricture. The specific treatment methods used may vary, but they can include balloon dilation, laser therapy, electrocautery, or incision.

5. When to use CPT code 52345

CPT code 52345 should be used when a provider performs cystourethroscopy with ureteroscopy specifically for the treatment of a ureteropelvic junction stricture. It is important to note that this code is not appropriate for other procedures or conditions unrelated to the treatment of a ureteropelvic junction stricture.

6. Documentation requirements

To support a claim for CPT 52345, the provider must document the following information:

• Patient’s diagnosis of a ureteropelvic junction stricture
• Details of the procedure, including the use of a cystoscope and ureteroscope
• Specific treatment methods employed, such as balloon dilation, laser therapy, electrocautery, or incision
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 52345, it is important to ensure that the procedure performed aligns with the official description of the code. The provider should also follow any specific billing guidelines provided by the payer. It is crucial to accurately document the procedure and include any necessary supporting documentation to justify the use of this code.

8. Historical information

CPT code 52345 was added to the Current Procedural Terminology system on January 1, 2001. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient presents with a ureteropelvic junction stricture, and the provider performs cystourethroscopy with ureteroscopy using balloon dilation to treat the stricture.
2. During a procedure, the provider identifies a ureteropelvic junction stricture and utilizes laser therapy to address the narrowing.
3. A patient undergoes cystourethroscopy with ureteroscopy, and the provider performs electrocautery to treat a ureteropelvic junction stricture.
4. Using incision as the treatment method, the provider performs cystourethroscopy with ureteroscopy to address a ureteropelvic junction stricture in a patient.
5. A provider performs cystourethroscopy with ureteroscopy and utilizes a combination of treatment methods, including balloon dilation and laser therapy, to address a ureteropelvic junction stricture.