2025 CPT code 52640
Effective Date: N/A Surgery - Surgical Procedures on the Urinary System Feed
Transurethral resection of postoperative bladder neck contracture.
Modifiers may be applicable. Modifier 22 (Increased Procedural Services) may be used for unusually complex or time-consuming procedures. Modifier 52 (Reduced Services) would be used if the procedure was not completed as planned.
Medical necessity for 52640 is established by documentation of significant bladder outlet obstruction due to postoperative bladder neck contracture, impacting the patient's ability to void normally and potentially leading to complications like urinary retention, hydronephrosis, or recurrent infections. Symptoms such as straining, hesitancy, weak stream, and incomplete emptying, along with confirmatory cystoscopic findings, support the medical necessity of the procedure.
The physician performs the procedure under anesthesia, using specialized endoscopic instruments to remove the scar tissue. They control bleeding and ensure proper placement of any drainage tubes post-procedure.
In simple words: This procedure removes scar tissue that has formed at the opening of the bladder, making it difficult to urinate. A thin tube with a camera and surgical tools is inserted through the urethra to reach the bladder neck. The scar tissue is then cut away. This procedure is often needed after prostate surgery.
This code represents a transurethral resection of a postoperative bladder neck contracture (BNC). A cystourethroscope is inserted to visualize the bladder neck and urethra. A meatotomy or urethrotomy may be performed to allow passage of the resectoscope. The resectoscope is then used to resect the scar tissue causing the contracture. A cautery may be used. Bleeding is controlled, and the scope is removed. A drainage tube may be placed. This procedure is often performed after prostate surgery.
Example 1: A patient experiences urinary retention after a radical prostatectomy due to BNC. Transurethral resection (52640) is performed to alleviate the obstruction., A patient with a history of TURP presents with a slow and weak urine stream. Cystoscopy confirms a bladder neck contracture, and 52640 is performed., Following radiation therapy for prostate cancer, a patient develops a bladder neck contracture with difficulty voiding. Code 52640 is used for the resection of the contracture.
Documentation should include details of the presenting symptoms, prior prostate procedures or treatments, cystoscopic findings confirming the presence and severity of the contracture, operative details (including size and location of the contracture, instruments used, and any complications), and post-operative instructions.
- Specialties:Urology
- Place of Service:Ambulatory Surgical Center, Hospital - Inpatient, Hospital - Outpatient