How To Use CPT Code 52351

CPT 52351 describes the diagnostic procedure of cystourethroscopy, which involves the inspection of the bladder, urethra, prostatic urethra, ureteric openings, and potentially the ureters and renal pelvis. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 52351?

CPT 52351 is used to describe a diagnostic cystourethroscopy procedure. During this procedure, a healthcare provider uses a cystoscope to visually examine the interior of the bladder, urethra, prostatic urethra, and ureteric openings. In some cases, the provider may also perform a ureteroscopy to inspect the ureters or a pyeloscopy to examine the renal pelvis.

2. Official Description

The official description of CPT code 52351 is: ‘Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic.’ It is important to note that CPT code 52351 should not be reported in conjunction with codes 52341, 52342, 52343, 52344, 52345, 52346, 52352-52356.

3. Procedure

1. Under anesthesia, the healthcare provider inserts a cystoscope into the urethra and advances it into the bladder.
2. The provider visually examines the bladder using the camera attached to the cystoscope, injecting sterile saline water if necessary to improve visibility.
3. If needed, the provider may exchange the cystoscope for a ureteroscope to inspect the ureters or a pyeloscope to examine the renal pelvis.
4. The provider does not perform any therapeutic procedures during this diagnostic cystourethroscopy.
5. Once the procedure is complete, the provider removes the scope and other instruments and drains the bladder.

4. Qualifying circumstances

CPT 52351 is typically performed on patients who require a diagnostic examination of the bladder, urethra, prostatic urethra, ureteric openings, ureters, or renal pelvis. It is important to note that CPT code 52351 should not be reported in conjunction with codes 52341, 52342, 52343, 52344, 52345, 52346, 52352-52356.

5. When to use CPT code 52351

CPT code 52351 should be used when a healthcare provider performs a diagnostic cystourethroscopy procedure. This code should not be used when other specific procedures, such as stone removal or biopsy, are performed during the same session. It is important to review the documentation and determine if any additional procedures were performed that may require separate coding.

6. Documentation requirements

To support a claim for CPT 52351, the healthcare provider must document the following information:

• Reason for the diagnostic cystourethroscopy
• Details of the procedure, including the use of a cystoscope, ureteroscope, or pyeloscope
• Findings from the examination, including any abnormalities or conditions observed
• Any additional procedures performed during the same session, if applicable
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 52351, it is important to ensure that the documentation supports the use of this specific code for a diagnostic cystourethroscopy procedure. It should not be reported in conjunction with codes 52341, 52342, 52343, 52344, 52345, 52346, 52352-52356. It is also recommended to check with the payer regarding the appropriate use of modifier 50 (Bilateral procedure) for cystourethroscopic procedures involving the ureters or kidneys, as CPT and Medicare guidelines may differ.

8. Historical information

CPT code 52351 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 urologist performs a diagnostic cystourethroscopy to examine the bladder and urethra of a patient experiencing recurrent urinary tract infections.
2. A healthcare provider uses a cystoscope to visually inspect the bladder and urethra of a patient with hematuria (blood in the urine).
3. A urologist performs a diagnostic cystourethroscopy to evaluate the cause of urinary incontinence in a patient.
4. A healthcare provider performs a cystourethroscopy to examine the bladder and urethra of a patient with suspected bladder cancer.
5. A urologist uses a cystoscope to visually inspect the bladder and urethra of a patient with urinary frequency and urgency.
6. A healthcare provider performs a diagnostic cystourethroscopy to evaluate the cause of recurrent kidney stones in a patient.
7. A urologist uses a cystoscope to visually examine the bladder and urethra of a patient with urinary retention.
8. A healthcare provider performs a cystourethroscopy to evaluate the cause of lower urinary tract symptoms in a patient.
9. A urologist uses a cystoscope to visually inspect the bladder and urethra of a patient with suspected urethral stricture.
10. A healthcare provider performs a diagnostic cystourethroscopy to evaluate the cause of urinary obstruction in a patient.