CPT 52356 can be billed for a cystourethroscopy procedure with ureteroscopy and/or pyeloscopy and the breaking of a stone with lithotripsy.
1. What Is CPT Code 52356?
CPT 52356 covers a cystourethroscopy procedure. During this procedure, a provider uses a cystoscope and passes it through the urethra of the patient into the bladder. They then inspect the;
- ureteric openings;
- prostatic urethra;
- urethra; and
- interior of the bladder.
The provider inspects the ureters (ureteroscopy) and/or the renal pelvis (pyeloscopy).
If the provider finds stones, they break them with lithotripsy. Then, an indwelling ureteral is inserted to keep the patient’s ureter open so fragments of the stone(s) can pass and it can heal.
CPT has defined the 52356 CPT code in their book as follows: “Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (e.g., Gibbons or double-J type).”
The 52356 CPT code procedure starts with anesthezing the patient before the cystoscope (rigid or flexible) is inserted into the urethra. Then, the provider moves it slowly up into the patient’s bladder.
The cystoscope camera gives the provider a view of the bladder and can make images of the interior. The urethra is inspected, and sterile saline is injected into the bladder for a better view of the wall.
After inspection of the wall, they might remove the cystoscope and use a ureteroscope for further assessment. The provider can also use the ureteroscope for bladder inspection because it is smaller.
Then, they use the ureteroscope and advance the scope into each ureter. Ureteroscopy is performed until the end of each ureter before they enter the renal pelvis and move into the calices or the renal pelvis.
The provider might discover a stone/stones in the ureter during the inspection.They then use a lithotripter device to destroy the stone and move it through the scope.
The fragments are washed out (as much as possible). They then place an indwelling stent into the patient’s ureter so the remaining pieces can leave the body and the ureter can heal properly.
Finally, the provider removes the cystoscope and other instruments and drains the patient’s bladder once the CPT 52356 procedure is complete.
4. Billing Guidelines
Do not bill CPT 52356 in combination with CPT 52352 and CPT 52353 if the procedure was performed on the same side.
It is unclear if this procedure should be billed with modifier 50 because there are two kidneys (bilateral), and two ureters (bilateral) but only one blatter.
Therefore, double-check the Medicare guidelines for CPT code 52356 before adding modifier 50 for a bilateral procedure to the claim. CPT guidelines and Medicare guidelines might differ for this code.