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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 procedure is performed through an incision in the ureter, allowing direct access to the ureteral lumen. The process begins with the creation of a small incision in the ureter, through which a ureteroscope—a specialized endoscopic instrument—is introduced. This instrument enables the physician to visually inspect the ureter for any abnormalities, such as abnormal tissue growths, foreign bodies, or calculi (stones). During the procedure, the ureter may be irrigated with normal saline to clear any debris or enhance visibility. Additionally, diagnostic or therapeutic solutions may be instilled into the ureter for further evaluation or treatment. In some cases, contrast material may be injected to facilitate ureteropyelography, a radiologic procedure that provides imaging of the urinary tract, although this imaging service is not included in the CPT® code for ureteral endoscopy. The procedure may also involve the removal of foreign bodies or calculi, which can be accomplished using a grasping device or basket that is advanced through the working channel of the ureteroscope. After the foreign body or calculus is captured, it is carefully removed from the ureter. The ureter is then re-inspected to ensure that no injury has occurred during the procedure, confirming the integrity of the ureter post-intervention. This comprehensive approach allows for effective diagnosis and treatment of various ureteral conditions while minimizing patient recovery time and complications.
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Ureteral endoscopy through ureterotomy is indicated for various conditions affecting the ureter. The following are explicitly provided indications for this procedure:
The procedure of ureteral endoscopy through ureterotomy involves several critical steps, each designed to ensure effective access and treatment of the ureter:
Post-procedure care following ureteral endoscopy through ureterotomy 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 prevent any potential complications related to the urinary tract. Follow-up appointments may be scheduled to assess recovery and ensure that the ureter is healing properly. Additionally, any necessary imaging studies or further interventions may be discussed based on the findings during the procedure.
| Short Descr | URETER ENDOSCOPY & TREATMENT | Medium Descr | NDSC URETEROTOMY RMVL FB/CALCULUS | Long Descr | Ureteral endoscopy through ureterotomy, 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) | 2 - Standard payment adjustment rules for multiple 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. | 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) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 101 - Transurethral excision, drainage, or removal urinary obstruction |
| 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). | 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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