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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 50961, is performed through an established ureterostomy, which is an opening created surgically to allow urine to exit the body directly from the ureter. During this procedure, a ureteroscope—a thin, flexible tube equipped with a camera and light—is introduced through the ureterostomy to visualize the ureter's interior. The primary goal of this endoscopic examination is to inspect the ureter for any abnormal tissue, foreign bodies, or calculi (stones) that may be obstructing the urinary tract. In addition to visual inspection, the procedure may involve irrigation of the ureter with normal saline to clear any debris or enhance visibility. Furthermore, diagnostic or therapeutic solutions can be instilled to aid in the evaluation or treatment of identified issues. If necessary, contrast material may be injected to perform ureteropyelography, a radiologic procedure that provides detailed images of the urinary tract, although this specific service is not included in the CPT® Code 50961. If a foreign body, such as a stent or a calculus, is detected during the inspection, the physician can utilize specialized instruments, such as a grasping device or basket, to capture and remove the obstruction. After the removal of the foreign body or calculus, the ureter is re-inspected to ensure that no injury has occurred during the procedure. This comprehensive approach allows for effective management of ureteral obstructions while minimizing the need for more invasive surgical interventions.
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The procedure described by CPT® Code 50961 is indicated for various conditions related to the ureter, particularly when there is a need to inspect and potentially remove foreign bodies or calculi. The following are specific indications for performing ureteral endoscopy through an established ureterostomy:
The procedure for CPT® Code 50961 involves several key steps that ensure thorough inspection and management of the ureter. The following outlines the procedural steps:
Following the ureteral endoscopy procedure, patients may be monitored for any immediate complications or adverse effects. Post-procedure care typically includes instructions for managing any discomfort, such as pain or irritation at the ureterostomy site. Patients may be advised to maintain hydration to facilitate urine flow and help flush out any residual debris. Follow-up appointments may be scheduled to assess recovery and ensure that the ureter is functioning properly. Additionally, any findings from the procedure may be discussed with the patient, along with recommendations for further treatment if necessary.
| Short Descr | URETER ENDOSCOPY & TREATMENT | Medium Descr | URETERAL ENDOSCOPY VIA URETEROST W/RMVL FB/STONE | Long Descr | Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus | 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 |
| 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). | 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. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, 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) | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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