In simple words: The doctor uses a thin, lighted tube to examine the inside of your bladder and urethra.They might also insert a small tube into the ureter, flush the bladder, or use special fluid to get better images. X-rays, if done, are billed separately.

This CPT code encompasses cystourethroscopy, which involves the insertion of a cystoscope through the urethra into the bladder to visualize and examine the bladder, urethra, and ureteral orifices.The procedure may include ureteral catheterization, irrigation of the bladder, instillation of fluids, and/or ureteropyelography (imaging of the ureters and renal pelvis using contrast media).Radiologic services, if performed, are reported separately.

Example 1: A patient presents with hematuria (blood in the urine).Cystourethroscopy with ureteral catheterization is performed to identify the source of bleeding.No additional procedures were required., A patient with suspected bladder stones undergoes cystourethroscopy.The procedure reveals stones, which are subsequently removed. The additional time required for stone removal warrants the use of modifier 22., A patient with a history of recurrent urinary tract infections undergoes a cystourethroscopy. The bladder is irrigated to remove any residual bacteria and instill medication.

* Pre-procedure urine test results.* Detailed operative report documenting the findings, procedures performed, and any specimens collected.* Anesthesia record, if applicable.* Pathology report if biopsy was performed.* Imaging reports, if applicable.

** If ureteropyelography is performed, the radiologic service should be reported separately using appropriate radiology CPT codes.Always consult the most current CPT manual and coding guidelines for accurate coding and billing.