2025 CPT code 52400
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Urinary System Feed
Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethral valves, or congenital obstructive hypertrophic mucosal folds.
Modifiers may be applicable to this code depending on specific circumstances (e.g., increased procedural services, reduced services, etc.).
Medical necessity for this procedure is established by the presence of congenital posterior urethral valves or congenital obstructive hypertrophic mucosal folds causing urinary obstruction or other related symptoms.Documentation should support the diagnosis and the need for the intervention.
The physician performs the cystourethroscopy, diagnoses the condition, and performs the necessary incision, fulguration, or resection.
In simple words: This procedure involves inserting a small camera through the urethra into the bladder to view the urinary tract. If the patient has birth defects causing urinary blockage, the doctor can use this procedure to correct them by cutting, burning, or removing excess tissue.
Cystourethroscopy is performed to inspect the interior of the bladder, urethra, prostatic urethra, and ureteric openings. A cystoscope is passed through the urethra into the bladder.This procedure is used to diagnose and treat various urinary tract conditions. During the procedure, if congenital posterior urethral valves or obstructive hypertrophic mucosal folds are discovered, the physician may incise, fulgurate (burn), or resect (remove) the obstructive tissue to enlarge the urethral passage.
Example 1: A newborn male presents with difficulty urinating. Cystourethroscopy reveals congenital posterior urethral valves causing obstruction. The physician incises the valves to relieve the obstruction., A young boy experiences weak urine stream and recurrent urinary tract infections. Cystourethroscopy is performed, and congenital obstructive hypertrophic mucosal folds are found. The folds are resected to improve urine flow., An adult male undergoes cystourethroscopy for evaluation of recurrent urinary tract infections. During the procedure, the physician identifies and fulgurates congenital posterior urethral valves that were not previously diagnosed.
Documentation should include operative report detailing the findings of the cystourethroscopy, the specific procedure performed (incision, fulguration, or resection), the location and size of the treated lesion, and any complications encountered. Pre- and post-operative diagnoses should also be documented.
- Specialties:Urology, Pediatric Urology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center