How To Use CPT Code 52354

CPT 52354 describes the procedure of cystourethroscopy, which involves the inspection of the bladder, urethra, prostatic urethra, and ureteric openings using a cystoscope. 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 52354?

CPT 52354 is used to describe the procedure of cystourethroscopy, which involves the examination of the bladder, urethra, prostatic urethra, and ureteric openings using a cystoscope. During this procedure, a qualified healthcare professional inserts a flexible or rigid cystoscope into the urethra and slowly advances it into the bladder. The camera attached to the cystoscope allows the healthcare professional to view the interior of the bladder on a monitor. The provider may also perform a ureteroscopy or pyeloscopy to inspect the ureters and renal pelvis.

2. Official Description

The official description of CPT code 52354 is: ‘Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion.’ This code specifically refers to the use of a cystoscope to inspect the bladder, urethra, prostatic urethra, and ureteric openings, with the possibility of performing a biopsy or fulguration of a lesion in the ureter or renal pelvis.

3. Procedure

1. The healthcare professional begins the procedure by inserting a cystoscope into the patient’s urethra and slowly advancing it into the bladder.
2. Using the camera attached to the cystoscope, the healthcare professional examines the interior of the bladder and may inject sterile saline water to improve visibility.
3. If necessary, the healthcare professional may switch to a ureteroscope to inspect the ureters and renal pelvis.
4. If a lesion is identified in the ureter or renal pelvis, the healthcare professional may perform a biopsy, which involves excising a small piece of tissue for further examination.
5. In some cases, the healthcare professional may choose to destroy the lesion using high-frequency electric current, a process known as fulguration.
6. Once the procedure is complete, the healthcare professional withdraws the instruments and drains the bladder.

4. Qualifying circumstances

CPT 52354 is typically performed on patients who require an examination of the bladder, urethra, prostatic urethra, ureteric openings, ureters, and renal pelvis. This procedure is commonly used to diagnose and treat conditions such as urinary tract infections, bladder stones, ureteral strictures, and renal pelvis tumors. The healthcare professional performing the procedure must have the necessary qualifications and expertise in cystourethroscopy.

5. When to use CPT code 52354

CPT code 52354 should be used when a healthcare professional performs cystourethroscopy with ureteroscopy and/or pyeloscopy, and also performs a biopsy and/or fulguration of a ureteral or renal pelvic lesion. This code accurately describes the comprehensive procedure involving the inspection of the bladder, urethra, prostatic urethra, ureteric openings, ureters, and renal pelvis, along with any necessary interventions.

6. Documentation requirements

To support a claim for CPT 52354, the healthcare professional must document the following information:

• Patient’s medical history and reason for the procedure
• Details of the cystourethroscopy, including the use of a cystoscope, ureteroscope, or pyeloscope
• Findings during the procedure, including any identified lesions
• Description of the biopsy or fulguration procedure, if performed
• Any complications or adverse events that occurred during or after the procedure
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 52354, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The healthcare professional should document the use of a cystoscope, ureteroscope, or pyeloscope, as well as any biopsy or fulguration procedures performed. It is also essential to follow the guidelines set by the payer regarding the use of modifiers and the reporting of bilateral procedures. Consulting with the payer before billing can help ensure accurate reimbursement.

8. Historical information

CPT code 52354 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 cystourethroscopy with ureteroscopy and identifies a suspicious lesion in the renal pelvis. The urologist performs a biopsy of the lesion for further examination.
2. A patient presents with recurrent urinary tract infections, and a urologist performs cystourethroscopy with ureteroscopy to investigate the cause. During the procedure, the urologist identifies a ureteral stricture and performs a fulguration to treat the condition.
3. A patient with a history of bladder stones undergoes cystourethroscopy with ureteroscopy. The urologist identifies multiple stones in the bladder and performs a biopsy to determine their composition.