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Ureteral endoscopy is a minimally invasive procedure that involves the examination and treatment of the ureter, which is the tube that carries urine from the kidney to the bladder. This specific procedure, identified by CPT® Code 50955, is performed through an established ureterostomy, which is an opening created surgically on the abdominal wall that allows urine to exit the body directly from the ureter. During the procedure, a ureteroscope, a specialized endoscopic instrument, is introduced through the ureterostomy to visualize the ureter's internal structure. The primary purpose of this endoscopy is to inspect the ureter for any abnormalities, such as abnormal tissue growths, foreign bodies, or calculi (stones). In addition to visual inspection, the procedure may involve irrigation of the ureter with normal saline to clear any obstructions or debris. Furthermore, diagnostic or therapeutic solutions may be instilled to aid in the evaluation or treatment of the ureter. If necessary, contrast material can be injected to perform ureteropyelography, a radiologic procedure that provides detailed imaging of the urinary tract, although this imaging service is not included in the CPT® Code 50955. A key component of this procedure is the biopsy, where biopsy forceps are introduced through the ureteroscope to obtain tissue samples for pathological examination. This allows for the diagnosis of potential malignancies or other pathological conditions affecting the ureter. Overall, CPT® Code 50955 encompasses a comprehensive approach to diagnosing and managing ureteral conditions through endoscopic techniques.
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Ureteral endoscopy through established ureterostomy, as described by CPT® Code 50955, is indicated for various clinical scenarios where direct visualization and intervention in the ureter are necessary. The following conditions may warrant this procedure:
The procedure for ureteral endoscopy through established ureterostomy involves several critical steps to ensure effective examination and treatment of the ureter. The following outlines the procedural steps:
Following the ureteral endoscopy through established ureterostomy, patients may experience some discomfort or mild pain at the site of the ureterostomy. It is essential to monitor for any signs of complications, such as bleeding, infection, or urinary obstruction. Patients are typically advised to maintain hydration and may be instructed to follow up with their healthcare provider for results of the biopsy and any further management based on the findings. Recovery time may vary depending on the individual and the complexity of the procedure, but most patients can resume normal activities within a short period, barring any complications.
| Short Descr | URETER ENDOSCOPY & BIOPSY | Medium Descr | URETERAL ENDOSCOPY VIA URETEROSTOMY W/BIOPSY | Long Descr | Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 3 - Special payment adjustment rules for multiple endoscopic procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Endoscopic Base Code | 50951 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P8I - Endoscopy - other | MUE | 1 | CCS Clinical Classification | 100 - Endoscopy and endoscopic biopsy of the urinary tract |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| Pre-1990 | Added | Code added. |
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