How To Use CPT Code 52500

CPT 52500 describes the transurethral resection of the bladder neck, which is a separate procedure used to treat urinary obstruction. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 52500?

CPT 52500 is a code used to describe the transurethral resection of the bladder neck, which is a procedure performed to treat urinary obstruction. During this procedure, a healthcare provider passes a cystourethroscope through the urethra to examine the interior of the urethra and bladder. They then excise tissue from the bladder neck to remove the obstruction and improve urinary expulsion.

2. Official Description

The official description of CPT code 52500 is: ‘Transurethral resection of bladder neck (separate procedure).’ This code is used when the provider performs a separate procedure to remove tissue from the bladder neck to treat urinary obstruction.

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The healthcare provider inserts a well-lubricated flexible or rigid cystourethroscope through the external opening of the urethra.
3. They examine the urethra and bladder, injecting sterile saline water into the bladder to improve the view.
4. The provider locates the hypertrophied or obstructive area of the bladder neck.
5. They excise the tissue from the bladder neck to remove the obstruction.
6. After completing the procedure, the provider removes the cystoscope.

4. Qualifying circumstances

CPT 52500 is performed when a patient has urinary obstruction that requires the removal of tissue from the bladder neck. This procedure is typically done to treat conditions such as hypertrophy or enlargement of the bladder neck. It is important to note that CPT 52500 is a separate procedure and should not be reported if the provider performs any other major procedure in the same location and session.

5. When to use CPT code 52500

CPT code 52500 should be used when a healthcare provider performs a separate procedure to remove tissue from the bladder neck to treat urinary obstruction. It is important to ensure that no other major procedure is performed in the same location and session to accurately report this code.

6. Documentation requirements

To support a claim for CPT 52500, the healthcare provider must document the following information:

• Patient’s diagnosis indicating the need for the procedure
• Details of the procedure performed, including the use of a cystourethroscope and the excision of tissue from the bladder neck
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 52500, ensure that the procedure is performed as a separate procedure and no other major procedure is performed in the same location and session. It is important to follow the specific guidelines provided by the payer to accurately report this code.

8. Historical information

CPT 52500 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A patient with urinary obstruction undergoes a transurethral resection of the bladder neck to remove tissue causing the obstruction.
2. A healthcare provider performs a separate procedure to excise hypertrophied tissue from the bladder neck in a patient with urinary obstruction.
3. During a cystourethroscopy, the provider identifies an obstructive area in the bladder neck and performs a transurethral resection to alleviate the urinary obstruction.
4. A patient with urinary retention undergoes a transurethral resection of the bladder neck to improve urinary expulsion.
5. A healthcare provider performs a separate procedure to remove obstructive tissue from the bladder neck in a patient with urinary obstruction.
6. During a cystourethroscopy, the provider locates an enlarged bladder neck and performs a transurethral resection to treat the urinary obstruction.
7. A patient with urinary hesitancy undergoes a transurethral resection of the bladder neck to alleviate the obstruction.
8. A healthcare provider performs a separate procedure to excise obstructive tissue from the bladder neck in a patient with urinary obstruction.
9. During a cystourethroscopy, the provider identifies a hypertrophied area in the bladder neck and performs a transurethral resection to treat the urinary obstruction.
10. A patient with urinary frequency undergoes a transurethral resection of the bladder neck to improve urinary flow.