Summary & Overview
CPT 52310: Cystourethroscopy with Removal of Stone, Foreign Body, or Stent
CPT code 52310 covers a simple cystourethroscopy performed to inspect the bladder, urethra (including prostatic urethra), and ureteric openings and to remove a foreign body, bladder stone, or displaced ureteral stent through the cystoscope. This endoscopic diagnostic and therapeutic procedure is commonly used across outpatient surgical settings and is important nationally for urology practices and facility billing due to its frequency and the need to correctly document the therapeutic removal component.
Key payers in the analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context, typical sites of service, common modifiers (listed separately), and benchmarking information where available. The publication outlines coding intent, clinical indications, and operational considerations that affect claim submission and reimbursement. It also highlights policy-related issues that influence coverage and payment across commercial and federal payers.
This summary is written for a national audience and focuses on the code’s clinical and billing significance, what to document to support use of 52310, and where organizations typically encounter this service in care delivery pathways.
Billing Code Overview
CPT code 52310 describes a simple cystourethroscopy with removal of a foreign body, stone, or displaced ureteral stent. The procedure involves inserting a cystoscope through the urethra into the bladder to inspect the interior of the bladder, the urethra including the prostatic urethra, and the ureteric orifices, and removing a foreign object or displaced stent through the cystoscope.
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Service type: Endoscopic diagnostic and therapeutic procedure (cystourethroscopy with object or stent removal)
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Typical site of service: Ambulatory surgical center or hospital outpatient department; may also be performed in an inpatient setting when clinically indicated.
Clinical & Coding Specifications
Clinical Context
A 58-year-old male presents to the urology clinic with acute onset dysuria, gross hematuria, and a history of passing small stones. Imaging (non-contrast CT or KUB x-ray) suggests a small bladder stone or a migrated ureteral stent fragment within the bladder. The patient is scheduled for a cystourethroscopy for direct visualization and removal of the foreign body/stone via the urethra under monitored anesthesia care or general anesthesia. The clinical workflow includes preoperative evaluation (consent, allergy and medication reconciliation, anticoagulation review), intraoperative cystoscopic inspection of the urethra, prostatic urethra, bladder, and ureteric orifices, retrieval of the stone or foreign body through the cystoscope with forceps or baskets, confirmation of complete removal, and brief postoperative recovery with discharge instructions and any necessary antibiotic prescription and follow-up.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable E/M service by the same physician on the same day as a procedure | Use when a separately identifiable evaluation and management visit is performed on the same day as 52310 (e.g., new problem evaluation leading to the procedure). |