How To Use CPT Code 52356

CPT 52356 refers to a cystourethroscopy procedure involving ureteroscopy, pyeloscopy, lithotripsy, and insertion of an indwelling ureteral stent. This article will cover topics such as the description, procedure, qualifying circumstances, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 52356.

1. What is CPT 52356?

CPT 52356 is a medical procedure code used to describe a cystourethroscopy with ureteroscopy and/or pyeloscopy, involving lithotripsy and the insertion of an indwelling ureteral stent. This code is utilized when a healthcare provider performs a diagnostic and therapeutic procedure to treat urinary tract stones and related conditions.

2. 52356 CPT code description

The official description of CPT code 52356 is: “Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type)”.

3. Procedure

The 52356 procedure involves the following steps:

1. The patient is placed under anesthesia.
2. The provider inserts a cystoscope or ureteroscope into the urethra and advances it into the bladder.
3. Saline water is injected into the bladder to improve visualization of the bladder wall.
4. The provider examines the urethra, ureteric openings, and ureters using the scope.
5. If a stone is found in the ureter, the provider uses a lithotripter device to break it apart.
6. The fragments are washed out, and an indwelling ureteral stent is inserted to facilitate passage of remaining fragments and allow the ureter to heal.
7. The instruments and cystoscope are withdrawn, and the bladder is drained.

4. Qualifying circumstances

Patients eligible to receive CPT code 52356 services are those who have been diagnosed with urinary tract stones or related conditions that require diagnostic and therapeutic intervention. This may include patients experiencing symptoms such as pain, hematuria, recurrent urinary tract infections, or obstruction of the urinary tract. The procedure is typically performed when conservative treatments have failed or are not appropriate for the patient’s condition.

5. When to use CPT code 52356

It is appropriate to bill the 52356 CPT code when a healthcare provider performs a cystourethroscopy with ureteroscopy and/or pyeloscopy, involving lithotripsy and the insertion of an indwelling ureteral stent to treat urinary tract stones or related conditions. The code should be used when the procedure is medically necessary and supported by appropriate documentation.

6. Documentation requirements

To support a claim for CPT 52356, the following information should be documented:

• Patient’s medical history and symptoms
• Physical examination findings
• Diagnostic tests and results (e.g., imaging studies)
• Indications for the procedure
• Details of the procedure, including the type of anesthesia used, instruments and devices utilized, and the steps performed
• Findings during the procedure, such as the location and size of the stone
• Outcome of the procedure, including the insertion of the ureteral stent and any complications encountered
• Postoperative care instructions and follow-up plan

7. Billing guidelines

When billing for CPT code 52356, it is essential to follow payer-specific guidelines and rules. Some payers may require the use of modifier 50 (Bilateral procedure) for cystourethroscopic procedures involving the ureters or kidneys. It is crucial to verify the payer’s requirements before billing to ensure proper reimbursement. Additionally, do not report CPT 52356 in conjunction with 52332 or 52353 when performed together on the same side.

8. Historical information

CPT 52356 was added to the Current Procedural Terminology system on January 1, 2014. There have been no updates to the code since its addition.

9. Similar codes to CPT 52356

Five similar codes to CPT 52356 and how they differ are:

• CPT 52332: Involves the insertion of a ureteral stent without lithotripsy.
• CPT 52353: Involves ureteroscopy and/or pyeloscopy with lithotripsy but without stent insertion.
• CPT 52352: Involves ureteroscopy and/or pyeloscopy without lithotripsy or stent insertion.
• CPT 52354: Involves ureteroscopy and/or pyeloscopy with biopsy or removal of a lesion.
• CPT 52355: Involves ureteroscopy and/or pyeloscopy with removal of a foreign body.

10. Examples

Here are 10 detailed examples of CPT code 52356 procedures:

1. A patient with a large ureteral stone causing severe pain undergoes CPT 52356 to break the stone and insert a stent for healing.
2. A patient with recurrent urinary tract infections due to a ureteral stone undergoes CPT 52356 for stone removal and stent placement.
3. A patient with hematuria and a confirmed ureteral stone undergoes CPT 52356 to treat the stone and alleviate symptoms.
4. A patient with a history of kidney stones presents with a new ureteral stone and undergoes CPT 52356 for stone fragmentation and stent insertion.
5. A patient with a ureteral stone causing urinary obstruction undergoes CPT 52356 to relieve the obstruction and promote healing.
6. A patient with a large renal pelvis stone undergoes CPT 52356 for stone fragmentation and stent placement to facilitate passage of fragments.
7. A patient with a ureteral stone that has failed to pass spontaneously undergoes CPT 52356 for stone removal and stent insertion.
8. A patient with a ureteral stone causing hydronephrosis undergoes CPT 52356 to alleviate the obstruction and prevent kidney damage.
9. A patient with a complex ureteral stone undergoes CPT 52356 for stone fragmentation and stent placement to ensure proper healing.
10. A patient with a history of multiple ureteral stones undergoes CPT 52356 for treatment of a new stone and stent placement to facilitate healing.