2025 CPT code 52235
Effective Date: N/A Surgery - Surgical Procedures on the Urinary System Feed
Cystourethroscopy with fulguration (including cryosurgery or laser surgery) of medium bladder tumor(s) (2.0 to 5.0 cm).
Modifiers may be applicable. Modifier 51 (Multiple Procedures) would be used if other distinct procedures are performed during the same session. Modifier 22 (Increased Procedural Services) may apply if the procedure is significantly more complex than usual (e.g., multiple tumors, difficult location). Other modifiers might apply in specific circumstances.Refer to current CPT guidelines for correct modifier usage.
Medical necessity for this procedure must be supported by the presence of a bladder tumor requiring treatment. The size of the tumor should be documented and fall within the 2.0-5.0 cm range for this code.The medical record should reflect the clinical rationale for choosing this specific method of treatment (fulguration, cryosurgery, laser).
The physician is responsible for preparing the patient, administering anesthesia or anesthetic gel, inserting and maneuvering the cystoscope, visualizing the bladder and urethra, and performing the tumor destruction using the appropriate method.
In simple words: The doctor uses a small, lighted tube with a camera (cystoscope) to look inside the bladder and destroy medium-sized tumors using electricity, freezing, or a laser.
This code describes a procedure where a cystoscope is inserted through the urethra into the bladder to visualize and treat medium-sized bladder tumors (2.0 to 5.0 cm). The procedure involves fulguration (destruction of tissue using high-frequency electric current), cryosurgery (freezing), or laser surgery to destroy the tumors.
Example 1: A patient presents with hematuria and a 3 cm bladder tumor is discovered during cystoscopy. The physician performs fulguration of the tumor using the cystoscope., A patient with a history of bladder cancer undergoes surveillance cystoscopy. A 2.5 cm recurrent tumor is found, and the physician uses cryosurgery to destroy it., A patient with a 4 cm bladder tumor unsuitable for traditional surgery undergoes cystoscopy and laser ablation of the tumor.
Documentation should include details of the cystoscopic findings, size and location of the tumor(s), method of destruction used (fulguration, cryosurgery, or laser), and any complications encountered. Pre- and post-operative diagnoses should also be documented.
- Specialties:Urology
- Place of Service:"Ambulatory Surgical Center", "Inpatient Hospital", "On Campus-Outpatient Hospital","Office"