Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.31
    OpenPayerPolicy UpdatesUrologyPHC California Cystourethroscopy Coverage | OpenPa…
    Ask Trek AI about this page
    ModifiedPHC CaliforniaPolicy N/A

    Outpatient Cystourethroscopy

    Customize your policy alerts

    Sign up for all phccalifornia policy alerts

    Know when phccalifornia releases new policies or updates existing guidance.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This policy governs when outpatient cystourethroscopy is medically necessary for diagnostic, therapeutic, and urinary tract management indications for PHC California members.

    Policy Summary
    PayerPHC California
    PolicyOutpatient Cystourethroscopy
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument at least 3 urinary tract infections in 12 months plus at least one listed risk factor when requesting coverage for recurrent UTI.
    SourceLink
    POLICY UPDATE CHANGES

    The Coding section was updated for 10/01/2023 ICD-10-CM changes and code N02.B9 was added.

    The Coding section was updated for 01/01/2023 HCPCS changes and codes C7550 and C7554 were added.

    The Coding section was updated for 10/01/2020 ICD-10-CM changes and code N02.A was added.

    The Discussion/General Information, Definitions, Clinical Indications, Coding, and References sections were revised during prior reviews.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    14
    Medically necessary indication categories
    3+UTIs defining recurrent UTI
    3Historical coding updates
    2HCPCS codes added
    6Peer-reviewed publications

    Medical Necessity Criteria

    Medically Necessary

    Covered when ANY of the following indications are met:

    Medically necessary indications

    • Gross hematuria without glomerular disease or infection: Gross hematuria without evidence of glomerular disease or infection
    • Gross hematuria with clots: Gross hematuria with blood clots
    • Microscopic hematuria with increased malignancy risk: Microscopic hematuria without evidence of glomerular disease, infection, or known cause of hematuria, with increased risk for malignancy
    • Stone management: Management of kidney stones unlikely to pass spontaneously
    • Suspected urinary tract injury or foreign body: Suspected surgical urinary tract injury or foreign body, including ureteral injury, incision into the bladder, or intravesical placement or erosion of mesh or suture
    • Urinary symptoms without infection: Urinary urgency, urinary frequency, urgency incontinence, or stress urinary incontinence when there is no urinary tract infection
    • Suspected urinary tract malignancy: Suspected malignant involvement of the urinary tract, including diagnosis and staging of bladder and gynecologic malignancies
    • Urine leakage from vagina: Urine leakage from the vagina, such as from a genitourinary fistula
    • Lower genital tract trauma or urethral stricture: Lower genital tract trauma with suspected urinary tract involvement, including urethral stricture
    • Post-void dribbling: Urine dribbling after voiding, such as from a urethral diverticulum
    • Therapeutic injection: Injection of therapeutic agents for urinary incontinence
    • Suprapubic catheter placement verification: Verification of suprapubic catheter placement
    • Ureteral stent removal: Removal of indwelling ureteral stents not amenable to an office-based procedure

    • Recurrent UTI with risk factor

      • Recurrent UTI risk factors

        • Prior urinary tract surgery or trauma
        • Gross hematuria after resolution of infection
        • Previous bladder or renal calculi
        • Obstructive symptoms, low uroflowmetry, or high post-void residual

          Obstructive symptoms include straining, weak stream, intermittency, or hesitancy.

        • Urea-splitting bacteria on culture, such as Proteus or Yersinia
        • Bacterial persistence after sensitivity-based therapy

    Not Medically Necessary

    Not covered when the following applies:

    Other indications: Outpatient cystourethroscopy is not medically necessary for any indication not listed above as medically necessary.

    Outpatient cystourethroscopy is not medically necessary when performed for any indication that is not listed in this policy as medically necessary.

    The listed procedure codes are not medically necessary when the policy’s medical-necessity criteria are not met.

    Coverage is not provided for outpatient cystourethroscopy performed for an indication not listed above as medically necessary.

    Procedure and Diagnosis Codes

    Covered CPT and HCPCS CodesmixedCovered
    52000Cystourethroscopy (separate procedure)
    52001Cystourethroscopy with irrigation and evacuation of multiple obstructing clots
    52005Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service
    52007Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with brush biopsy of ureter and/or renal pelvis
    52010Cystourethroscopy, with ejaculatory duct catheterization, with or without irrigation, instillation, or duct radiography, exclusive of radiologic service
    52204Cystourethroscopy, with biopsy(s)
    52214Cystourethroscopy, with fulguration, including cryosurgery or laser surgery, of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands
    52224Cystourethroscopy, with fulguration, including cryosurgery or laser surgery, or treatment of minor lesions less than 0.5 cm, with or without biopsy
    52234Cystourethroscopy, with fulguration, including cryosurgery or laser surgery, and/or resection of small bladder tumors, 0.5 up to 2.0 cm
    52235Cystourethroscopy, with fulguration, including cryosurgery or laser surgery, and/or resection of medium bladder tumors, 2.0 to 5.0 cm
    1–10 of 18
    1/2
    ICD-10 DiagnosisICD-10
    C64.1-C68.9Malignant neoplasms of urinary tract
    C79.00-C79.19Secondary malignant neoplasm of kidney and renal pelvis, bladder and other and unspecified urinary organs
    D09.0-D09.19Carcinoma in situ of bladder, other and unspecified urinary organs
    D17.71-D17.72Benign lipomatous neoplasm of kidney, other genitourinary organs
    D30.00-D30.9Benign neoplasm of urinary organs
    D41.00-D41.9Neoplasm of uncertain behavior of urinary organs
    D49.4-D49.5Neoplasms of unspecified behavior of bladder, other genitourinary organs
    N02.0-N02.B9Recurrent and persistent hematuria
    N13.1-N13.9Obstructive and reflux uropathy
    N20.0-N21.9Calculus of kidney and ureter, lower urinary tract
    1–10 of 19
    1/2
    All diagnoses, including specified malignant neoplasms of female genital organsICD-10
    No codes listed
    Not medically necessary procedure codesCPTNot Covered
    No codes listed
    ICD-10-CM codes added in historical updatesICD-10
    N02.B9Added to the Coding section with the 10/01/2023 ICD-10-CM changes; full code description is not provided in this window.
    N02.AAdded to the Coding section with the 10/01/2020 ICD-10-CM changes; full code description is not provided in this window.
    HCPCS codes added in historical updatesHCPCS
    C7550Added to the Coding section with the 01/01/2023 HCPCS changes; full code description is not provided in this window.
    C7554Added to the Coding section with the 01/01/2023 HCPCS changes; full code description is not provided in this window.
    Recurrent urinary tract infection
    Definition3 or more urinary tract infections in 12 months

    Documentation and Denial Considerations

    Denial Risk

    Confirm a listed medically necessary indication

    Outpatient cystourethroscopy is considered not medically necessary for any indication not listed above as medically necessary. The listed procedure codes are also not medically necessary when the medical-necessity criteria are not met.

    Denial Risk

    Document recurrent UTI frequency and risk factor

    For recurrent urinary tract infection, document 3 or more urinary tract infections in 12 months and at least one specified risk factor; recurrent UTI without a listed risk factor does not satisfy this criterion.

    • Prior urinary tract surgery or trauma
    • Gross hematuria after resolution of infection
    • Previous bladder or renal calculi
    • Obstructive symptoms, low uroflowmetry, or high post-void residual
    • Urea-splitting bacteria on culture
    • Bacterial persistence after sensitivity-based therapy

    Clinical Background

    Cystourethroscopy combines visualization of the bladder and urethra. It may be used diagnostically to examine these structures for disease or abnormalities, or therapeutically to pass instruments and perform treatment. The procedure may be performed with local, regional, or general anesthesia.

    Key Definitions

    Cystourethroscopy
    DefinitionA 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.
    Gross hematuria
    DefinitionBlood in the urine which is visible to the naked eye.
    Hematuria
    DefinitionBlood in the urine.
    Microscopic hematuria
    Definition
    Policy Summary
    PayerPHC California
    PolicyOutpatient Cystourethroscopy
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument at least 3 urinary tract infections in 12 months plus at least one listed risk factor when requesting coverage for recurrent UTI.
    SourceLink
    On This Page
    Medical Necessity CriteriaProcedure and Diagnosis CodesDocumentation and Denial ConsiderationsClinical BackgroundKey Definitions
  1. Prior abdominopelvic malignancy
  2. Diabetes or otherwise immunocompromised status
  3. Pneumaturia, fecaluria, anaerobic bacteria, or a history of diverticulitis
  4. Repeated pyelonephritis with fevers, chills, vomiting, or costovertebral tenderness
  5. Asymptomatic microhematuria after resolution of infection
  6. Prior abdominopelvic malignancy
  7. Diabetes or otherwise immunocompromised status
  8. Pneumaturia, fecaluria, anaerobic bacteria, or history of diverticulitis
  9. Repeated pyelonephritis
  10. Asymptomatic microhematuria after resolution of infection
    11. Blood in the urine which is only visible by a microscope.