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Official Description

Cystotomy or cystostomy; with cryosurgical destruction of intravesical lesion

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 51030 involves a cystotomy or cystostomy, which is a surgical intervention performed on the urinary bladder. In this procedure, the urinary bladder is either fully exposed and incised or accessed through a smaller incision made over the bladder, where the bladder wall is punctured to allow entry into the internal lumen. This access is crucial for the subsequent treatment of intravesical lesions, which are abnormal growths or tissues located within the bladder. The primary technique utilized in this procedure is cryosurgical destruction, where a cryoprobe is introduced through the incision to freeze the abnormal tissue. This freezing process effectively destroys the targeted lesions. It is important to note that multiple freeze-thaw cycles may be necessary to ensure complete destruction of all abnormal tissue. This method is an alternative to other techniques such as fulguration or the insertion of radioactive materials, which are also used to treat similar lesions within the bladder. The choice of technique depends on the specific characteristics of the lesion and the overall treatment plan for the patient.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 51030 is indicated for the treatment of intravesical lesions within the urinary bladder. These lesions may include abnormal growths or tissues that require surgical intervention to prevent complications such as obstruction, bleeding, or progression to malignancy. The specific indications for performing a cystotomy or cystostomy with cryosurgical destruction may include:

  • Intravesical Lesions Abnormal growths or tumors located within the bladder that necessitate removal or destruction.
  • Bladder Obstruction Conditions where lesions obstruct normal urinary flow, leading to potential complications.
  • Hematuria Presence of blood in the urine that may be associated with lesions requiring intervention.
  • Suspicion of Malignancy Lesions that may be cancerous or precancerous, warranting surgical treatment to prevent progression.

2. Procedure

The procedure for CPT® Code 51030 involves several critical steps to ensure effective treatment of the intravesical lesions. The following procedural steps are outlined:

  • Step 1: Surgical Access The first step involves gaining access to the urinary bladder. This can be achieved by either fully exposing the bladder through a cystotomy or making a smaller incision over the bladder to puncture the bladder wall, allowing entry into the internal lumen.
  • Step 2: Introduction of Cryoprobe Once access is obtained, a cryoprobe is introduced through the incision. This specialized instrument is designed to deliver extreme cold to the targeted abnormal tissue.
  • Step 3: Cryosurgical Destruction The cryoprobe is positioned at the site of the lesion, and the freezing process begins. The cryoprobe freezes the abnormal tissue, effectively destroying it. This may require multiple freeze-thaw cycles to ensure that all abnormal tissue is completely eradicated.

3. Post-Procedure

After the completion of the cystotomy or cystostomy with cryosurgical destruction, post-procedure care is essential for patient recovery. Patients may be monitored for any immediate complications, such as bleeding or infection. It is also important to assess urinary function and ensure that the bladder is healing properly. Follow-up appointments may be scheduled to evaluate the success of the procedure and to monitor for any recurrence of lesions. Patients may be advised on hydration and urinary habits to promote healing and prevent complications. Additionally, any specific instructions regarding activity restrictions or medication management should be provided to ensure optimal recovery.

Short Descr INCISE & TREAT BLADDER
Medium Descr CSTOTOMY/CSTOST CRYOSURG DSTRJ INTRAVESICAL LES
Long Descr Cystotomy or cystostomy; with cryosurgical destruction of intravesical lesion
Status Code Active Code
Global Days 090 - Major Surgery
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
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
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P1G - Major procedure - Other
MUE Not applicable/unspecified.
CCS Clinical Classification 112 - Other OR therapeutic procedures of urinary tract
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Notes
2024-12-31 Deleted Code Deleted.
Pre-1990 Added Code added.
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