How To Use CPT Code 52442

CPT 52442 describes the procedure of cystourethroscopy with the insertion of an additional permanent adjustable transprostatic implant. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 52442?

CPT 52442 can be used to describe the procedure in which a healthcare provider uses a cystourethroscope to insert an additional permanent adjustable transprostatic implant. This code is used when the provider needs to retract prostatic lobes that obstruct the urethra, and it is an add-on code that should be reported with an appropriate primary code for the initial implant.

2. Official Description

The official description of CPT code 52442 is: ‘Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure).’ This code should be used in conjunction with CPT code 52441 for the primary procedure, and it should not be reported without an appropriate primary code.

3. Procedure

1. The healthcare provider prepares and anesthetizes the patient for the procedure.
2. Using a cystourethroscope, the provider visualizes the urethra to identify the site of obstruction in the prostatic lobe.
3. An additional permanent adjustable transprostatic implant is inserted at the identified site to retract the prostatic lobe.
4. The provider performs a final scope examination of the implant to ensure proper placement.
5. The cystourethroscope is then removed, completing the procedure.

4. Qualifying circumstances

CPT 52442 is used when the patient has prostatic lobes that obstruct the urethra, requiring the insertion of additional permanent adjustable transprostatic implants. The number of implants inserted may vary based on the size and shape of the prostatic lobes. It is important to note that this code should only be reported in conjunction with the appropriate primary code for the initial implant (CPT 52441).

5. When to use CPT code 52442

CPT code 52442 should be used when the healthcare provider needs to insert an additional permanent adjustable transprostatic implant during a cystourethroscopy procedure. It is important to ensure that the primary code for the initial implant (CPT 52441) is also reported in conjunction with this code. This code should not be reported without an appropriate primary code.

6. Documentation requirements

To support a claim for CPT 52442, the healthcare provider must document the following information:

• Indication for the procedure and the need for additional permanent adjustable transprostatic implants
• Details of the cystourethroscopy procedure, including the visualization of the urethra and identification of the site of obstruction
• Number of additional implants inserted
• Final scope examination of the implant
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 52442, ensure that the appropriate primary code for the initial implant (CPT 52441) is also reported. This is an add-on code and should not be reported without the primary code. It is important to follow payer guidelines and ensure accurate reporting of the procedure and any additional implants inserted.

8. Historical information

CPT 52442 was added to the Current Procedural Terminology system on January 1, 2015. There have been no updates to the code since its addition.

9. Examples

1. A urologist performing a cystourethroscopy procedure and inserting an additional permanent adjustable transprostatic implant to retract prostatic lobes obstructing the urethra.
2. A patient with prostatic lobes causing urinary obstruction undergoing a cystourethroscopy procedure with the insertion of multiple permanent adjustable transprostatic implants.
3. A healthcare provider performing a cystourethroscopy procedure and inserting an additional permanent adjustable transprostatic implant to alleviate symptoms of urinary retention.
4. A patient with prostatic lobes causing recurrent urinary tract infections undergoing a cystourethroscopy procedure with the insertion of an additional permanent adjustable transprostatic implant.
5. A urologist performing a cystourethroscopy procedure and inserting an additional permanent adjustable transprostatic implant to improve urinary flow in a patient with benign prostatic hyperplasia.
6. A healthcare provider inserting an additional permanent adjustable transprostatic implant during a cystourethroscopy procedure to relieve symptoms of urinary urgency and frequency in a patient with prostatic lobes obstructing the urethra.
7. A patient with prostatic lobes causing urinary incontinence undergoing a cystourethroscopy procedure with the insertion of multiple permanent adjustable transprostatic implants.
8. A urologist performing a cystourethroscopy procedure and inserting an additional permanent adjustable transprostatic implant to treat recurrent urinary retention in a patient with prostatic lobes obstructing the urethra.
9. A healthcare provider inserting an additional permanent adjustable transprostatic implant during a cystourethroscopy procedure to alleviate symptoms of incomplete bladder emptying in a patient with prostatic lobes causing urinary obstruction.
10. A patient with prostatic lobes causing recurrent urinary tract infections undergoing a cystourethroscopy procedure with the insertion of an additional permanent adjustable transprostatic implant to improve urinary flow.