How To Use CPT Code 52630

CPT 52630 describes the procedure for resecting residual or regrowth of obstructive prostate tissue, including control of postoperative bleeding. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 52630?

CPT 52630 can be used to describe the surgical procedure performed by a healthcare provider to remove residual or regrowth of obstructive prostate tissue. This procedure includes controlling postoperative bleeding and may also involve other related procedures such as vasectomy, meatotomy, cystourethroscopy, urethral calibration, and/or dilation, and internal urethrotomy.

2. Official Description

The official description of CPT code 52630 is: ‘Transurethral resection; residual or regrowth of obstructive prostate tissue including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included).’

3. Procedure

1. The healthcare provider prepares the patient and administers anesthesia.
2. A well-lubricated flexible or rigid cystourethroscope is inserted through the external opening of the urethra.
3. The provider examines the urethra and bladder using the cystourethroscope.
4. The cystoscope is advanced to the prostate to locate the residual or regrowth of obstructive prostate tissue.
5. The provider performs resection of the tissue using blunt and sharp dissection techniques.
6. If necessary, the provider may also perform additional procedures such as meatotomy, urethral calibration, and/or dilation.
7. Postoperative bleeding is controlled using electrocauterization.
8. After completing the procedure, the provider removes the cystoscope and inserts a catheter into the bladder.

4. Qualifying circumstances

CPT 52630 is performed when there is residual or regrowth of obstructive prostate tissue that requires resection. This procedure is typically performed after a previous related procedure. The provider must ensure complete removal of the tissue and control postoperative bleeding. Modifier 78 should be appended if the resection is performed within the postoperative period of a related procedure performed by the same physician.

5. When to use CPT code 52630

CPT code 52630 should be used when the healthcare provider performs a complete resection of residual or regrowth of obstructive prostate tissue, including control of postoperative bleeding. It is important to ensure that the procedure meets the specific criteria outlined in the official description of the code.

6. Documentation requirements

To support a claim for CPT 52630, the healthcare provider must document the following information:

• Indication for the procedure, including the presence of residual or regrowth of obstructive prostate tissue
• Details of the procedure performed, including any additional related procedures
• Date of the procedure
• Start and end time of the procedure
• Any complications or postoperative care provided
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 52630, ensure that the procedure meets the specific criteria outlined in the official description. Modifier 78 should be appended if the resection is performed within the postoperative period of a related procedure performed by the same physician. It is important to follow the appropriate coding guidelines and documentation requirements to ensure accurate and timely reimbursement.

8. Historical information

CPT 52630 was added to the Current Procedural Terminology system on January 1, 1990. There was a code change on January 1, 2009, which added the specification of resection of regrowth of obstructive tissue longer than one year postoperative.

9. Examples

1. A healthcare provider performs a transurethral resection to remove residual prostate tissue in a patient who previously underwent a prostatectomy.
2. A patient presents with regrowth of obstructive prostate tissue after a previous transurethral resection. The healthcare provider performs a complete resection and controls postoperative bleeding.
3. A healthcare provider performs a transurethral resection to remove residual prostate tissue and also performs a meatotomy and urethral dilation during the same procedure.
4. A patient undergoes a transurethral resection for the complete removal of regrowth of obstructive prostate tissue, and the healthcare provider uses electrocauterization to control postoperative bleeding.
5. A healthcare provider performs a transurethral resection to remove residual prostate tissue and also performs an internal urethrotomy during the same procedure.
6. A patient presents with regrowth of obstructive prostate tissue one year after a previous transurethral resection. The healthcare provider performs a complete resection to remove the tissue and controls postoperative bleeding.
7. A healthcare provider performs a transurethral resection to remove residual prostate tissue and also performs a vasectomy during the same procedure.
8. A patient undergoes a transurethral resection for the complete removal of regrowth of obstructive prostate tissue, and the healthcare provider uses electrocauterization to control postoperative bleeding.
9. A healthcare provider performs a transurethral resection to remove residual prostate tissue and also performs a cystourethroscopy during the same procedure.
10. A patient presents with regrowth of obstructive prostate tissue after a previous transurethral resection. The healthcare provider performs a complete resection and controls postoperative bleeding.