How To Use CPT Code 52355

CPT 52355 describes a specific procedure involving cystourethroscopy, ureteroscopy, and/or pyeloscopy, with the resection of a ureteral or renal pelvic tumor. 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 examples of when CPT 52355 may be used.

1. What is CPT Code 52355?

CPT 52355 is used to describe a procedure that involves the inspection of the bladder, urethra, prostatic urethra, ureteric openings, and the resection of a ureteral or renal pelvic tumor. This code is used when a healthcare provider performs a cystourethroscopy, ureteroscopy, and/or pyeloscopy, and identifies and removes a tumor in the ureter or renal pelvis.

2. Official Description

The official description of CPT code 52355 is: ‘Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of ureteral or renal pelvic tumor.’

3. Procedure

1. The healthcare provider begins by inserting a cystoscope into the urethra and slowly advancing it into the bladder.
2. Using the camera attached to the cystoscope, the provider examines the urethra and injects sterile saline water into the bladder to improve visibility.
3. The provider may switch to a ureteroscope, a smaller instrument, to inspect the ureters.
4. The ureteroscope is advanced into each ureter, allowing the provider to visualize the upper end of the ureters where they enter the renal pelvis.
5. If a tumor is identified in the ureter or renal pelvis, the provider uses a cutting device to resect and remove the tumor.
6. Once the procedure is complete, the instruments and cystoscope are withdrawn, and the bladder is drained.

4. Qualifying circumstances

CPT 52355 is performed when a patient has a ureteral or renal pelvic tumor that requires resection. The procedure is typically performed by a healthcare provider who specializes in urology. It is important to note that this code is specific to the resection of tumors in the ureter or renal pelvis and should not be used for other procedures or conditions.

5. When to use CPT code 52355

CPT code 52355 should be used when a healthcare provider performs a cystourethroscopy, ureteroscopy, and/or pyeloscopy, and identifies and resects a ureteral or renal pelvic tumor. It is important to ensure that the procedure performed aligns with the specific requirements outlined in the code description.

6. Documentation requirements

To support a claim for CPT 52355, the healthcare provider must document the following information:

• Patient’s diagnosis indicating the presence of a ureteral or renal pelvic tumor
• Details of the procedure performed, including the use of cystourethroscopy, ureteroscopy, and/or pyeloscopy
• Date of the procedure
• Specific location of the tumor within the ureter or renal pelvis
• Details of the resection technique used
• Any additional findings or procedures performed during the same session
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 52355, it is important to ensure that the procedure performed aligns with the code description. Additionally, it is crucial to follow any specific billing guidelines provided by the payer. Modifier 50 (Bilateral procedure) may be appropriate in certain cases, but it is recommended to check with the payer to confirm the appropriate use of modifiers. It is also important to review any specific guidelines related to reporting CPT 52355 with other codes.

8. Historical information

CPT code 52355 was added to the Current Procedural Terminology system on January 1, 2001. Since its addition, there have been no updates or changes to the code.

9. Examples

1. A urologist performs a cystourethroscopy, ureteroscopy, and pyeloscopy on a patient with a ureteral tumor. The tumor is identified and resected during the procedure.
2. During a diagnostic cystourethroscopy, a urologist discovers a renal pelvic tumor. The tumor is resected using a ureteroscope.
3. A patient with a history of bladder cancer undergoes a surveillance cystourethroscopy. A ureteral tumor is identified and removed during the procedure.
4. A urologist performs a cystourethroscopy, ureteroscopy, and pyeloscopy on a patient with recurrent urinary tract infections. A ureteral tumor is discovered and resected.
5. During a routine cystourethroscopy, a urologist identifies a renal pelvic tumor. The tumor is resected using a combination of ureteroscopy and pyeloscopy.
6. A patient with a history of kidney stones undergoes a cystourethroscopy, ureteroscopy, and pyeloscopy. A ureteral tumor is discovered and removed during the procedure.