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Ureteral endoscopy is a minimally invasive procedure that involves the examination and treatment of the ureter, which is the duct that carries urine from the kidney to the bladder. This specific procedure, identified by CPT® Code 50957, is performed through an established ureterostomy, which is an opening created surgically to allow urine to exit the body directly from the ureter. The ureteroscope, a specialized instrument equipped with a camera and light, is introduced through this stoma or a ureteral catheter that exits the skin. During the procedure, the physician inspects the ureter for any abnormalities, such as abnormal tissue growths, foreign bodies, or calculi (stones). The procedure may also involve the irrigation of the ureter with normal saline to clear any obstructions or debris. Additionally, diagnostic or therapeutic solutions can be instilled into the ureter for further evaluation or treatment. If necessary, contrast material may be injected to perform ureteropyelography, a radiologic examination of the ureter and renal pelvis, although this specific service is not included in the CPT® code description. In cases where abnormal tissue is identified, the physician may perform fulguration, which involves the use of an electrocautery device to destroy the abnormal tissue. Alternatively, a laser or cryoprobe may be utilized for tissue destruction. The procedure may also include an incision of the abnormal tissue, which can be performed in conjunction with fulguration. If a biopsy is indicated, tissue samples can be obtained using biopsy forceps introduced through the ureteroscope. This comprehensive approach allows for both diagnostic and therapeutic interventions during a single procedure, enhancing patient care and outcomes.
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The procedure described by CPT® Code 50957 is indicated for various conditions affecting the ureter, particularly when there is a need to inspect or treat abnormalities. The following are the explicitly provided indications for performing ureteral endoscopy through an established ureterostomy:
The procedure involves several critical steps, each aimed at ensuring thorough examination and treatment of the ureter. The following procedural steps are outlined:
Post-procedure care following ureteral endoscopy through an established ureterostomy typically involves monitoring the patient for any immediate complications, such as bleeding or infection. Patients may be advised to maintain hydration to facilitate urine flow and help flush out any residual debris. Follow-up appointments may be necessary to assess the results of any biopsies taken and to ensure proper healing of the ureter. Additionally, the physician may provide specific instructions regarding activity restrictions and signs of complications that should prompt immediate medical attention.
| Short Descr | URETER ENDOSCOPY & TREATMENT | Medium Descr | URETERAL ENDOSCOPY W/DEST&/INC W/WO BIOPSY | Long Descr | Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without 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 | 101 - Transurethral excision, drainage, or removal urinary obstruction |
| 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. | 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). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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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