2025 CPT code 52356
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Surgery - Urinary System Surgery Feed
Cystourethroscopy with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent.
Modifiers 50 (bilateral procedure) and 51 (multiple procedures) may apply depending on the circumstances.Modifier 58 (staged or related procedure) may be appropriate in certain cases.Check payer guidelines.
Medical necessity is established by the presence of a ureteral stone causing symptoms (flank pain, hematuria, obstruction).Documentation of the stone's presence via imaging (X-ray, CT scan) and clinical correlation is required.
The urologist is responsible for performing the entire procedure, including the insertion and placement of the stent.Anesthesiology services may be separately reported if provided.
In simple words: The doctor uses a thin, flexible tube with a camera (cystoscope) to examine the bladder and ureters.If stones are found, they are broken up using a special device.A small tube (stent) is then placed in the ureter to help the area heal and allow for the passage of any remaining stone fragments.
This CPT code encompasses a comprehensive urological procedure involving cystourethroscopy (examination of the bladder, urethra, and ureteral openings), ureteroscopy (examination of the ureters), and/or pyeloscopy (examination of the renal pelvis).The procedure further includes lithotripsy (breaking up of calculi) and the insertion of an indwelling ureteral stent (e.g., a double-J stent) to facilitate drainage and healing.Ureteral catheterization is considered inclusive within this code.
Example 1: A 55-year-old male presents with right flank pain and hematuria.Cystourethroscopy reveals a ureteral stone in the right ureter.Ureteroscopy, lithotripsy, and placement of a double-J stent are performed. Code 52356 is reported., A 40-year-old female undergoes cystourethroscopy for evaluation of recurrent urinary tract infections.Ureteroscopy reveals bilateral ureteral stones.Lithotripsy is performed bilaterally, and bilateral double-J stents are placed.Code 52356 is reported with modifier 50 (bilateral procedure)., A 62-year-old male with a history of nephrolithiasis presents with severe left flank pain and oliguria.Imaging reveals a large left ureteral stone.Cystourethroscopy, left ureteroscopy, lithotripsy, and placement of a left ureteral stent are performed using a flexible ureteroscope. Code 52356 is reported.
Detailed operative report specifying the type of cystoscope used, the location and size of the stone(s), the type of lithotripsy performed, the type and placement of the stent(s), and any complications.
** Always verify payer-specific coding and reimbursement policies before billing.Document all aspects of the procedure thoroughly to support medical necessity and appropriate coding.
- Revenue Code: P8E (Endoscopy - Cystoscopy)
- RVU: The RVUs for this code will vary depending on the specific payer and location (facility vs. office).In 2014, Medicare's office-based RVUs were approximately 8.00 work, 3.09 practice, and 0.74 malpractice.
- Global Days: The global period for this procedure is dependent on payer policy and specific circumstances.It may vary.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule: RVUs were approximately 8.00 work, 3.09 practice, and 0.74 malpractice for office-based settings in 2014 under Medicare.Actual reimbursement varies.
- Specialties:Urology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center