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    v1.0.31
    OpenPayerPolicy UpdatesUrologyPHC California Cystourethroscopy Coverage | OpenPa…
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    ModifiedPositive Healthcare (PHC) California – AIDS Healthcare FoundationPolicy CG-UM-004

    Outpatient Cystourethroscopy

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    This guideline governs when outpatient cystourethroscopy is medically necessary for diagnostic and therapeutic urologic indications. It applies to providers evaluating or requesting outpatient cystourethroscopy and related procedures.

    Policy Summary
    PayerPositive Healthcare (PHC) California – AIDS Healthcare Foundation
    PolicyOutpatient Cystourethroscopy
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateN/A
    Next Review DateN/A
    Key ActionConfirm that the indication is listed as medically necessary and that all applicable criteria are met before requesting outpatient cystourethroscopy.
    SourceLink
    POLICY UPDATE CHANGES

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

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

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

    The policy history records updates to the References sections.

    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+ in 12 monthsRecurrent UTI threshold
    11Recurrent UTI risk factors
    3Historical coding updates

    Medical Necessity Criteria

    Outpatient cystourethroscopy is not medically necessary for any indication not listed as medically necessary in this guideline.

    Outpatient cystourethroscopy is not medically necessary when the indication is not listed in the guideline or when the applicable medical-necessity criteria are not met.

    Applicable Procedure and Diagnosis Codes

    When services may be medically necessary when criteria are met for outpatient proceduresCPTCovered
    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) Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder.
    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 (less than 0.5 cm) lesion(s) with or without biopsy.
    52234Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of small bladder tumor(s) (0.5 up to 2.0 cm).
    52235Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of medium bladder tumor(s) (2.0 to 5.0 cm).
    1–10 of 16
    1/2
    When services may be medically necessary when criteria are met for outpatient proceduresHCPCSCovered
    C7550Cystourethroscopy, with biopsy(ies) with adjunctive blue light cystoscopy with fluorescent imaging agent.
    C7554Cystourethroscopy with adjunctive blue light cystoscopy with fluorescent imaging agent.
    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
    When services are not medically necessarymixedNot Covered
    52000, 52001, 52005, 52007, 52010, 52204, 52214, 52224, 52234, 52235, 52240, 52250, 52260, 52265, 52270, 52275, C7550, C7554The procedure codes listed above when criteria are not met.
    ICD-10-CM codes mentioned in historical coding updatesICD-10
    N02.B9
    N02.A
    HCPCS codes mentioned in historical coding updatesHCPCS
    C7550
    C7554
    Recurrent urinary tract infection
    Definition3 or more urinary tract infections in 12 months

    When Criteria Are Not Met

    Denial Risk

    Confirm a listed indication and meet all applicable criteria

    Outpatient cystourethroscopy is considered not medically necessary for any indication not listed as medically necessary or when the applicable criteria are not met. Procedure codes listed in the policy are not medically necessary when criteria are not met.

    Clinical Background

    Cystourethroscopy combines visualization of the bladder and urethra and may also permit passage of instruments for treatment. The procedure may be performed with local, regional, or general anesthesia. Potential indications include hematuria, urinary symptoms, malignancy evaluation, urinary tract injury, stones, recurrent urinary tract infection with specified risk factors, and other urinary tract conditions.

    Key Definitions

    Cystourethroscopy
    DefinitionA surgical procedure that combines cystoscopy and urethroscopy to examine the bladder and urethral lumen for urethral diseases or abnormalities.
    Gross hematuria
    DefinitionBlood in the urine that is visible to the naked eye.
    Hematuria
    DefinitionBlood in the urine.
    Microscopic hematuria
    Definition
    Policy Summary
    PayerPositive Healthcare (PHC) California – AIDS Healthcare Foundation
    PolicyOutpatient Cystourethroscopy
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateN/A
    Next Review DateN/A
    Key ActionConfirm that the indication is listed as medically necessary and that all applicable criteria are met before requesting outpatient cystourethroscopy.
    SourceLink
    On This Page
    Medical Necessity CriteriaApplicable Procedure and Diagnosis CodesWhen Criteria Are Not MetClinical BackgroundKey Definitions
    Blood in the urine that is visible only by a microscope.