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2025 CPT code 52310

Cystourethroscopy with removal of a foreign body, calculus, or ureteral stent from the urethra or bladder (separate procedure); simple.

This code should be reported as a separate procedure only when it is not performed in conjunction with other related procedures in the same anatomical area. If performed with an unrelated procedure, modifier 59 may be appended.

Modifiers such as 22 (Increased Procedural Services), 52 (Reduced Services), 59 (Distinct Procedural Service), and others may be applicable depending on the specific circumstances of the procedure.

Medical necessity must be established for this procedure. This includes documenting the symptoms, diagnostic findings (e.g., imaging studies), and the clinical rationale for the removal of the foreign body/calculus/stent.

The physician is responsible for preparing the patient, administering anesthesia, performing the cystourethroscopy, removing the foreign body/calculus/stent, and ensuring appropriate post-procedure care.

In simple words: The doctor uses a small, lighted tube with a camera (cystoscope) to look inside your bladder and urethra. If they find a foreign object, stone, or misplaced stent, they can remove it using tiny tools passed through the same tube.

This procedure involves inserting a cystoscope (a lighted tubular instrument with a camera) into the urethra and advancing it into the bladder to visualize the interior of the bladder, urethra, prostatic urethra, and ureteric openings. If a foreign body, calculus (stone), or displaced ureteral stent is found, specialized grasping forceps are inserted through the cystoscope to extract the object. The procedure is considered "simple" when it can be performed without additional maneuvers or complications.

Example 1: A patient presents with a displaced ureteral stent causing discomfort. The physician performs a cystourethroscopy and removes the stent using a grasping forceps., A child inserts a small bead into their urethra. The physician performs a cystourethroscopy to visualize and retrieve the foreign body., A patient experiences recurrent urinary tract infections due to a small bladder stone. The physician uses a cystourethroscopy to remove the stone.

Documentation should include details of the visualization of the bladder and urethra, identification of the foreign body/calculus/stent, method of removal, and any complications encountered. Medical necessity for the procedure should also be clearly documented.

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