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The procedure described by CPT® Code 51715 involves the endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck. This intervention is specifically aimed at addressing mild incontinence, which can occur due to the thinning of tissues at the bladder outlet. The procedure utilizes a cystourethroscope, a specialized instrument that allows for direct visualization of the bladder outlet during the injection process. The physician carefully injects the implant material, which is typically collagen or a newer formulation that consists of a water-based gel containing carbon-coated beads. This material is strategically placed into the submucosal tissues surrounding the urethra and/or bladder neck to enhance tissue volume and support. By plumping up the bladder outlet tissues, the procedure aims to alleviate any laxity in the bladder outlet valve, thereby improving its function and reducing episodes of incontinence. It is important to note that achieving optimal results may require multiple injection sessions, often two to three, spaced over several weeks, to ensure adequate valve closure and effective management of incontinence symptoms.
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The endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck is indicated for the treatment of mild incontinence. This condition may arise from the thinning of tissues at the bladder outlet, which can lead to insufficient closure of the bladder outlet valve during activities such as coughing, sneezing, or physical exertion.
The procedure begins with the placement of a cystourethroscope at the bladder outlet. This instrument allows the physician to visualize the area effectively while performing the injection. Once the cystourethroscope is in position, the physician prepares to inject the implant material. The material, which may consist of collagen or a newer formulation made of a water-based gel with carbon-coated beads, is then injected into the submucosal tissues surrounding the urethra and/or bladder neck. This injection aims to enhance the volume of the tissues, thereby providing additional support to the bladder outlet. After the injection is completed, the cystourethroscope is carefully removed. It is important to note that the injection procedure may not achieve the desired results in a single session; therefore, it may be necessary for the patient to undergo two to three additional injection sessions over the course of several weeks to attain optimal valve closure and effectively manage incontinence.
After the injection procedure, patients may be monitored for any immediate complications or adverse reactions. It is essential to provide appropriate post-procedure care, which may include instructions on activity restrictions and signs of potential complications to watch for. Patients should be informed that multiple sessions may be required to achieve the desired level of valve closure and to effectively manage incontinence. Follow-up appointments will be necessary to assess the effectiveness of the treatment and determine if additional injections are needed.
| Short Descr | ENDOSCOPIC INJECTION/IMPLANT | Medium Descr | NDSC NJX IMPLT MATRL URT&/BLDR NCK | Long Descr | Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck | 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) | 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 | ASC Payment Indicator | Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P8I - Endoscopy - other | MUE | 1 | CCS Clinical Classification | 106 - Genitourinary incontinence procedures |
| 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). | GC | This service has been performed in part by a resident under the direction of a teaching physician | SG | Ambulatory surgical center (asc) facility service | GA | Waiver of liability statement issued as required by payer policy, individual case | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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. | 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. | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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. | 74 | Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 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.) | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AG | Primary physician | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | GY | Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit | GZ | Item or service expected to be denied as not reasonable and necessary | JZ | Zero drug amount discarded/not administered to any patient | KX | Requirements specified in the medical policy have been met | LT | Left side (used to identify procedures performed on the left side of the body) | Q5 | Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | RT | Right side (used to identify procedures performed on the right side of the body) | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 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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| 2020-01-01 | Note | AMA Guidelines removed. |
| 1994-01-01 | Added | First appearance in code book in 1994. |
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