CG-SURG-51 Outpatient Cystourethroscopy

Outpatient cystourethroscopy is considered medically necessary for any of the following indications:

Outpatient cystourethroscopy is considered not medically necessary for any other indication not listed above as medically necessary.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met for outpatient procedures:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

A cystoscopy is a surgical procedure in which a tube with a small camera on the end (endoscope) is inserted into the bladder to examine the lumen of the bladder, urethra, and the prostate. A related procedure, the urethroscopy, is done to examine the urethral lumen to look for urethral diseases or abnormalities. For the cystoscopy, the endoscope is inserted into the urethra which allows visualization of both the bladder and the urethra, thus the term cystourethroscopy. In addition to the camera, small instruments can also be passed through the endoscope that can be used to treat urinary problems. A diagnostic cystourethroscopy can be done as part of an evaluation of abnormal symptoms or laboratory findings. Cystourethroscopy can be performed with local anesthesia while the member is awake, but it can also be performed during or after pelvic surgery with regional or general anesthesia.

Hematuria
Hematuria can occur with or without other urinary tract symptoms. Without symptoms, hematuria may still be indicative of urinary or bladder problems. A 2012 study by Cha reported on 1182 participants who presented with asymptomatic hematuria. A total of 245 participants were found to have bladder cancer; 138 had low-grade tumors while 97 participants had high-grade tumors. While there are limitations to this study, including a possible increased probability of bladder cancer in the cohort based on local referral patterns, the results indicate that hematuria should not be ignored.

Goldberg and colleagues (2008) reviewed the charts of 1584 participants who had lower urinary tract symptoms and subsequent cystourethroscopy in an attempt to ascertain whether microscopic hematuria was a reliable predictor of cancer risk. Microscopic hematuria was found in 14.8% of the participants, with 1.7% then found to have biopsy-confirmed bladder cancer. Among the participants without hematuria, 0.45% were found to have bladder cancer and 60% of the participants presented with a normal initial dipstick urinalysis. While this study has some limitations including its retrospective design, the findings suggest that cystourethroscopy can be used for the evaluation of lower urinary tract symptoms including hematuria.

In a 2015 study of 109 participants with hematuria, Ahmed and colleagues compared transabdominal ultrasound to cystourethroscopy. All participants had both ultrasound and cystourethroscopy. The authors concluded that while ultrasound can be used as a first-line imaging tool for evaluation of hematuria in settings where cystourethroscopy is not available, it cannot replace cystourethroscopy as the gold standard for evaluation of hematuria.

Kidney Stones
Whether or not a stone passes spontaneously, stone passage can depend on the size and/or location of the stone. According to a 2016 American Urological Association guideline for the surgical management of stones, ureteroscopy can be used for mid or distal ureteral stones.

Urinary Tract Infection
In 2019 the American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction published their guideline regarding recurrent uncomplicated urinary tract infection in women. This guideline refers to “an otherwise healthy adult female with an uncomplicated recurrent urinary tract infection." The authors define a recurrent urinary tract infection as “two separate culture-proven episodes of acute bacterial cystitis and associated symptoms within six months or three episodes within one year.” Upon evaluation, according to expert opinion, for a healthy adult individual with an uncomplicated recurrent urinary tract infection, cystoscopy and upper tract imaging should not be routinely done.

While cystourethroscopy is considered to be the gold standard procedure for many indications and is a low-risk surgical procedure, like all surgical procedures it is not without risk. A 2014 study by Rambachan and colleagues reported on surgical outcomes and the rate of hospital readmissions following urological surgery. In looking at 7795 participants, outpatient urological surgery had a 3.7% readmission rate within 30 days. Cystourethroscopy and resection of bladder tumor was the most common procedure that had been performed. However, it is important to keep in mind that certain gynecologic surgical procedures themselves are considered to be high-risk for complications and the addition of cystourethroscopy may help to avoid additional surgery.

Cystourethroscopy: A surgical procedure which combines a cystoscopy and a urethroscopy. It can be done to examine the bladder and urethral lumen to look for urethral diseases or abnormalities.

Microscopic hematuria: Blood in the urine which is only visible by a microscope.

Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

Subject: Outpatient Cystourethroscopy
Guideline #: CG-SURG-51	Publish Date: 06/28/2024
Status: Reviewed	Last Review Date: 05/09/2024

CPT
52000	Cystourethroscopy (separate procedure)
52001	Cystourethroscopy with irrigation and evacuation of multiple obstructing clots
52005	Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service;
52007	Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with brush biopsy of ureter and/or renal pelvis
52010	Cystourethroscopy, with ejaculatory duct catheterization, with or without irrigation, instillation, or duct radiography, exclusive of radiologic service
52204	Cystourethroscopy, with biopsy(s)
52214	Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands
52224	Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy
52234	Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)
52235	Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm)
52240	Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s)
52250	Cystourethroscopy with insertion of radioactive substance, with or without biopsy or fulguration
52260	Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia
52265	Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia
52270	Cystourethroscopy, with internal urethrotomy; female
52275	Cystourethroscopy, with internal urethrotomy; male

HCPCS
C7550	Cystourethroscopy, with biopsy(ies) with adjunctive blue light cystoscopy with fluorescent imaging agent
C7554	Cystourethroscopy with adjunctive blue light cystoscopy with fluorescent imaging agent

ICD-10 Diagnosis
	All diagnoses, including, but not limited to:
C51.0-C57.9	Malignant neoplasm of vulva, vagina, cervix uteri, corpus uteri, uterus, ovary, other and unspecified female genital organs
C64.1-C68.9	Malignant neoplasms of urinary tract
C79.00-C79.19	Secondary malignant neoplasm of kidney and renal pelvis, bladder and other and unspecified urinary organs
D09.0-D09.19	Carcinoma in situ of bladder, other and unspecified urinary organs
D17.71-D17.72	Benign lipomatous neoplasm of kidney, other genitourinary organs
D30.00-D30.9	Benign neoplasm of urinary organs
D41.00-D41.9	Neoplasm of uncertain behavior of urinary organs
D49.4-D49.5	Neoplasms of unspecified behavior of bladder, other genitourinary organs
N02.0-N02.B9	Recurrent and persistent hematuria
N13.1-N13.9	Obstructive and reflux uropathy
N20.0-N21.9	Calculus of kidney and ureter, lower urinary tract
N22	Calculus of urinary tract in diseases classified elsewhere
N30.00-N30.91	Cystitis
N32.0	Bladder-neck obstruction
N34.0-N34.3	Urethritis and urethral syndrome
N35.010-N35.92	Urethral stricture
N39.0	Urinary tract infection, site not specified
R80.0-R82.99	Abnormal findings on examination of urine, without diagnosis
Z85.50-Z85.59	Personal history of malignant neoplasm of urinary tract
Z87.440-Z87.448	Personal history of diseases of the urinary system

Status	Date	Action
Reviewed	05/09/2024	Medical Policy & Technology Assessment Committee (MPTAC) review. Revised References section.
	09/27/2023	Updated Coding section with 10/01/2023 ICD-10-CM changes; added N02.B9 to end of range.
Reviewed	5/11/2023	MPTAC review. Updated References section.
	12/28/2022	Updated Coding section with 01/01/2023 HCPCS changes; added C7550 and C7554.
Reviewed	05/12/2022	MPTAC review. Updated Discussion/General Information and References sections.
Reviewed	05/13/2021	MPTAC review. Updated References section. Reformatted Coding section.
	10/01/2020	Updated Coding section with 10/01/2020 ICD-10-CM changes; added N02.A.
Reviewed	05/14/2020	MPTAC review.
Reviewed	06/06/2019	MPTAC review. Updated Discussion/General Information and References sections.
Reviewed	07/26/2018	MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 10/01/2018 ICD-10-CM changes to diagnosis range N35.010-N35.92.
Reviewed	08/03/2017	MPTAC review. Updated Definitions section.
Reviewed	08/04/2016	MPTAC review. Updated formatting in Clinical Indications section. Updated Discussion/General Information and Reference sections. Removed ICD-9 codes from Coding section.
New	08/06/2015	MPTAC review. Initial document development.