2025 CPT code 52351
(Active) Effective Date: N/A Revision Date: N/A Urology - Ureter and Pelvis Transurethral Surgical Procedures Surgery Feed
Diagnostic cystourethroscopy with ureteroscopy and/or pyeloscopy.
Modifiers 50 (bilateral procedure), 51 (multiple procedures), and 25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure) may apply in certain circumstances.
Medical necessity for 52351 is established when there is a clinical indication suggesting abnormalities of the bladder, ureters, or renal pelvis that necessitate visual examination.This might be due to symptoms like hematuria, recurrent UTIs, flank pain, or abnormal findings on imaging studies.
The clinical responsibility lies with a urologist or other qualified physician trained in performing cystoscopy, ureteroscopy, and pyeloscopy.The physician is responsible for proper insertion of the instruments, visualization of the urinary tract, interpretation of findings, and documenting the procedure and any findings.
- Surgery
- 52351 falls under the broader category of Ureter and Pelvis Transurethral Surgical Procedures within the CPT codebook's Surgery section. It is a diagnostic code, distinguished from therapeutic codes within this subcategory.
In simple words: The doctor uses a thin, lighted tube inserted into the bladder through the urethra to examine the bladder, urethra, and the openings to the tubes leading to the kidneys.If needed, smaller tubes are also used to view the tubes leading to the kidneys and the kidney itself. This is a visual examination only; no treatment is done.
This CPT code encompasses a diagnostic procedure involving the insertion of a cystoscope through the urethra into the bladder to visualize the bladder, urethra, prostatic urethra, and ureteric orifices.It further includes ureteroscopy (inspection of the ureters) and/or pyeloscopy (inspection of the renal pelvis) as needed for complete evaluation. No therapeutic interventions are performed.The procedure involves the use of a cystoscope, potentially exchanged for a smaller ureteroscope and pyeloscopy to access the ureters and renal pelvis for visualization.Sterile saline may be used to improve visualization.
Example 1: A 60-year-old male presents with hematuria and suspected bladder stones. A diagnostic cystourethroscopy with ureteroscopy is performed to visualize the bladder and ureters, ruling out stones and identifying the source of bleeding., A 45-year-old female presents with recurrent urinary tract infections.A diagnostic cystourethroscopy with pyeloscopy is performed to assess for anatomical abnormalities in the ureters and renal pelvis that may contribute to the infections., A 72-year-old male presents with flank pain and microscopic hematuria. A diagnostic cystourethroscopy is performed which includes ureteroscopy to investigate potential ureteral stones or other sources of bleeding within the urinary tract.
Complete operative report detailing the insertion and use of the cystoscope, ureteroscope (if used), and pyeloscopy (if used).Specific findings for each anatomical location visualized must be documented, including any abnormalities noted.Imaging reports, if any, should be included.The anesthesia record must also be documented.
** The use of 52351 is limited to diagnostic procedures.Any therapeutic interventions, such as stone removal, biopsy, or stent placement, require additional, separate coding.
- Payment Status: Active
- Modifier TC rule: Not applicable for this diagnostic code; modifier TC only applies to procedures with a professional and technical component.
- Specialties:Urology
- Place of Service:Office, Hospital (Inpatient or Outpatient), Ambulatory Surgical Center