52346

CPT Code 52346 - Cystourethroscopy with Ureteroscopy; Treatment of Intra-Renal Stricture

Code Description

52346: Cystourethroscopy with ureteroscopy; with treatment of intra-renal stricture (eg, balloon dilation, laser, electrocautery, and incision)¹

This code describes a minimally invasive endoscopic procedure that combines cystourethroscopy (examination of the bladder and urethra) with ureteroscopy (examination of the ureter and renal pelvis) for the specific purpose of treating strictures (narrowings) located within the kidney (intra-renal). The procedure is performed through the natural urinary tract without any external incisions.

Procedural Components

Cystourethroscopy

Insertion of a cystoscope through the urethra into the bladder to:

• Visualize the bladder lining
• Identify the ureteral orifice
• Assess bladder pathology
• Provide access for ureteroscope advancement²

Ureteroscopy

Advancement of a ureteroscope (rigid or flexible) through the ureteral orifice, up the ureter, and into the renal collecting system (renal pelvis and calyces) to:

• Visualize the intrarenal anatomy
• Locate the stricture
• Access the treatment site³

Treatment Modalities Included

• Balloon dilation: Inflation of a balloon catheter at the stricture site to mechanically widen the narrowed segment
• Laser incision/ablation: Use of laser energy (typically holmium laser) to incise or vaporize scar tissue
• Electrocautery: Application of electrical current to cut or coagulate tissue
• Cold knife incision: Direct incision of the stricture using endoscopic instruments⁴

Work Relative Value Units (wRVU)

2025 Medicare Values

• Work RVU: 7.55⁵
• Facility PE RVU: 10.82
• Non-Facility PE RVU: 20.71
• Malpractice RVU: 0.90
• Total RVU (Facility): 19.27
• Total RVU (Non-Facility): 29.16

National Payment (2025 Conversion Factor: $32.35)

• Facility Setting: ~$623.29
• Non-Facility Setting: ~$943.17

Note: These values are national averages and subject to GPCI (Geographic Practice Cost Index) adjustments based on locality.⁶

Historical Context

The relatively high work RVU (7.55) reflects:

• Complexity of navigating the ureter and intrarenal collecting system
• Technical skill required for flexible ureteroscopy
• Time and intensity of treating intrarenal strictures
• Risk of complications (ureteral perforation, bleeding, stricture)
• Need for precise endoscopic visualization and instrumentation

Assistant Surgeon Information

Assistant Payable Status

Indicator: 2⁷

This indicator means assistant surgeon services are allowed and payable for this procedure. The assistant surgeon must:

• Actively assist the primary surgeon throughout the procedure
• Document their role in the operative report
• Use appropriate modifier (see below)

Assistant Surgeon Payment

• Medicare: 16% of the primary surgeon fee
• Commercial payers: Typically 16-20% of primary surgeon fee
• Example: If primary surgeon receives $623.29,assistantreceives$99.73 (16%)

When Assistant Surgeon is Medically Necessary

• Complex intrarenal anatomy requiring additional hands
• Difficult ureteroscopy (tortuous ureter, previous surgery)
• Patient comorbidities increasing procedural difficulty
• Teaching institution requirements
• Bilateral procedures requiring coordination⁸

Common Modifiers

Laterality Modifiers (CRITICAL - Required for Accurate Coding)

• 50: Bilateral procedure
  • Use when procedure performed on both kidneys during same session
  • Payment: 150% of unilateral fee (Medicare)
  • Some payers require two line items instead
• RT: Right side
• LT: Left side

IMPORTANT: Laterality modifiers are mandatory for CPT 52346. Claims submitted without appropriate laterality modifier will likely be denied or delayed.⁹

Assistant Surgeon Modifiers

• -80: Assistant surgeon (physician)
  • Payment: 16% of primary surgeon fee
• -81: Minimum assistant surgeon
  • Payment: 16% of primary surgeon fee
  • Used when assistant provides minimal assistance
• -82: Assistant surgeon when qualified resident not available
  • Payment: 16% of primary surgeon fee
  • Teaching hospitals only
• -AS: Assistant surgeon (physician assistant, nurse practitioner, or clinical nurse specialist)
  • Payment: Varies by payer (typically 13.6-16%)

Distinct Procedural Service Modifiers

• -59: Distinct procedural service
  • Overcomes NCCI edits when appropriate
  • Use when procedures are distinct and separate
• -XS: Separate structure
  • More specific than -59
  • Use for procedures on different anatomic structures (e.g., bilateral)
• -XU: Unusual non-overlapping service
  • Use for services that don’t overlap in typical circumstances
• -XE: Separate encounter
  • Use for procedures performed at different sessions on same day
• -XP: Separate practitioner
  • Use when different practitioner performs the procedure

Reduction/Discontinuation Modifiers

• -22: Increased procedural services
  • Use for unusually complex cases
  • Requires detailed documentation
  • Additional payment: 20-50% (varies by payer)
• -52: Reduced services
  • Use when procedure partially performed
  • Payment reduced proportionally
• -53: Discontinued procedure
  • Use when procedure started but stopped before completion
  • Document reason for discontinuation
• -76: Repeat procedure by same physician
• -77: Repeat procedure by different physician

Reporting Modifiers

• -26: Professional component (NOT applicable - CPT 52346 is procedure-only)
• -TC: Technical component (NOT applicable)

Note: CPT 52346 is a surgical procedure code without separate professional/technical components.¹⁰

Includes

The following are bundled into CPT 52346 and should NOT be separately coded:

1. Cystourethroscopy (diagnostic visualization)
2. Ureteral catheterization (for guidewire placement, contrast injection)
3. Ureteroscopy (advancement of scope through ureter)
4. Diagnostic nephroscopy/pyeloscopy (visualization of renal pelvis)
5. Fluoroscopic guidance (if used for procedure)
6. Radiologic supervision and interpretation of any imaging performed during procedure
7. All treatment modalities performed on the stricture:
   • Balloon dilation equipment and inflation
   • Laser fiber usage and activation
   • Electrocautery application
   • Incision instruments
8. Guidewire placement and manipulation
9. Contrast injection for visualization (if performed)
10. Retrograde pyelography performed as part of the procedure
11. Multiple attempts at stricture treatment during same session¹¹

Excludes

The following procedures may be separately reportable when performed with CPT 52346:

Add-on Codes (When Clinically Indicated)

• 52332+: Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type)
  • Report separately when stent placed after stricture treatment
  • Most commonly used add-on code with 52346
  • Payment: ~$150-200 additional
  • Note: Per CPT guidelines revised in 2014, 52332 may be reported in addition to 52346 when a self-retaining indwelling stent is placed¹²

Separate Session Procedures

• 52000: Cystourethroscopy (separate procedure)
  • Only if performed at different session
  • NOT billable same day as 52346 without modifier
• Diagnostic ureteroscopy codes (52351, 52352)
  • Only if performed on opposite side or different session

Different Anatomic Site Procedures

• 52344: Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture
  • Can be coded with 52346 if treating both ureteral AND intrarenal stricture
  • Requires modifier 59 or XS
• 52345: Cystourethroscopy with ureteroscopy; with treatment of ureteropelvic junction stricture
  • Can be coded with 52346 if treating both UPJ AND intrarenal stricture
  • Requires modifier 59 or XS

Imaging Codes (Usually NOT Separately Billable)

• Fluoroscopy performed during the procedure is bundled
• Separate pre-operative or post-operative imaging studies may be billable with appropriate documentation¹³

Common Associated Diagnoses (ICD-10-CM)

Primary Indications (Most Common)

Hydronephrosis with Stricture

• N13.0: Hydronephrosis with ureteropelvic junction obstruction
  • HCC: May contribute to HCC 138 (Chronic Kidney Disease, Stage 3-4) if CKD documented
  • Clinical: Narrowing at UPJ causing kidney swelling
  • Laterality: Requires additional code for bilateral (N13.0 applies to either side)
• N13.1: Hydronephrosis with ureteral stricture, not elsewhere classified
  • HCC: May contribute to HCC 138 if CKD present
  • Clinical: Ureteral narrowing with kidney swelling
  • Use additional code: B95-B97 if infection present
• N13.2: Hydronephrosis with renal and ureteral calculous obstruction
  • HCC: May contribute to HCC 138 if CKD documented
  • Clinical: Stone causing stricture and hydronephrosis
  • Common scenario: Impacted stone requiring stricture treatment
• N13.30: Unspecified hydronephrosis
  • HCC: May contribute to HCC 138 if CKD present
  • Clinical: Use when specific cause not documented
  • Coding tip: More specific code preferred when etiology known
• N13.39: Other hydronephrosis
  • HCC: May contribute to HCC 138 if CKD documented
  • Clinical: Hydronephrosis from other specified causes

Stricture Without Hydronephrosis

• N13.5: Crossing vessel and stricture of ureter without hydronephrosis
  • HCC: No direct HCC mapping
  • Clinical: Extrinsic compression or intrinsic narrowing
  • Common causes: Aberrant vessels, retroperitoneal fibrosis
• N28.82: Megaloureter
  • HCC: No
  • Clinical: May have associated intrarenal stricture

Infection-Related

• N13.6: Pyonephrosis
  • HCC: No direct HCC, but severe infection may contribute to sepsis HCCs
  • Clinical: Infected, obstructed kidney - URGENT indication
  • Severity: Often requires immediate drainage
  • Use additional code: Organism if identified (B95-B97)
• N10: Acute pyelonephritis
  • HCC: No
  • Clinical: Kidney infection, may have associated obstruction
  • Use additional code: Organism if known
• N11.1: Chronic obstructive pyelonephritis
  • HCC: May contribute depending on severity and CKD
  • Clinical: Chronic infection with obstruction

Post-Procedural/Acquired Strictures

• N13.8: Other obstructive and reflux uropathy
  • HCC: No direct mapping
  • Clinical: Catch-all for various obstructive causes
• N99.112: Postprocedural urethral stricture, male
  • HCC: No
  • Note: This is urethral, not ureteral - different anatomy
• T83.112A: Breakdown (mechanical) of indwelling ureteral stent, initial encounter
  • HCC: No
  • Clinical: Stent malfunction causing stricture
  • 7th character: A (initial), D (subsequent), S (sequela)

Secondary/Contributing Diagnoses

Calculus-Related

• N20.0: Calculus of kidney
  • HCC: No
  • Clinical: Renal stone may cause secondary stricture
• N20.1: Calculus of ureter
  • HCC: No
  • Clinical: Ureteral stone, may need stricture treatment after passage
• N20.2: Calculus of kidney with calculus of ureter
  • HCC: No
  • Clinical: Bilateral stone disease

Congenital Anomalies

• Q62.11: Congenital occlusion of ureteropelvic junction
  • HCC: No
  • Clinical: Present from birth, may require treatment in adulthood
• Q62.12: Congenital occlusion of ureterovesical orifice
  • HCC: No
• Q62.39: Other obstructive defects of renal pelvis and ureter
  • HCC: No

Malignancy (Requires Different Treatment Approach)

• C64.9: Malignant neoplasm of unspecified kidney, except renal pelvis
  • HCC: HCC 11 (Colorectal, Bladder, and Other Cancers)
  • RAF: Significant risk adjustment factor increase
  • Laterality: Specify C64.1 (right) or C64.2 (left) when known
• C65.9: Malignant neoplasm of unspecified renal pelvis
  • HCC: HCC 11
  • RAF: Significant impact on risk scores
  • Specify: C65.1 (right) or C65.2 (left) when documented
• C66.9: Malignant neoplasm of unspecified ureter
  • HCC: HCC 11
  • Specify: C66.1 (right) or C66.2 (left)
• C79.01: Secondary malignant neoplasm of right kidney and renal pelvis
  • HCC: HCC 9 (Metastatic Cancer)
  • RAF: Higher than primary cancer HCC
  • Clinical: Metastatic disease to kidney
• C79.02: Secondary malignant neoplasm of left kidney and renal pelvis
  • HCC: HCC 9

Chronic Kidney Disease (CKD)

When hydronephrosis or stricture leads to renal impairment:

• N18.30: Chronic kidney disease, stage 3 unspecified
  • HCC: HCC 138 (Chronic Kidney Disease, Stage 3-4)
  • RAF: Moderate impact
• N18.31: Chronic kidney disease, stage 3a
  • HCC: HCC 138
  • GFR: 45-59 mL/min/1.73m²
• N18.32: Chronic kidney disease, stage 3b
  • HCC: HCC 138
  • GFR: 30-44 mL/min/1.73m²
• N18.4: Chronic kidney disease, stage 4 (severe)
  • HCC: HCC 138
  • GFR: 15-29 mL/min/1.73m²
  • RAF: Higher impact
• N18.5: Chronic kidney disease, stage 5
  • HCC: HCC 137 (Chronic Kidney Disease, Stage 5)
  • GFR: <15 mL/min/1.73m² or on dialysis
  • RAF: Highest CKD impact

Sepsis/Systemic Infection

• A41.9: Sepsis, unspecified organism
  • HCC: HCC 2 (Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock)
  • RAF: Very high impact
  • Clinical: Urosepsis from obstructed infected kidney
• R65.20: Severe sepsis without septic shock
  • HCC: HCC 2
  • RAF: Major impact
  • Requires: Underlying infection code
• R65.21: Severe sepsis with septic shock
  • HCC: HCC 2
  • RAF: Highest sepsis impact
  • Clinical: Life-threatening, emergency drainage needed

HCC Summary: Most hydronephrosis codes do NOT directly map to HCCs unless chronic kidney disease is also documented. Malignancy and sepsis diagnoses have significant HCC impact.¹⁴

MS-DRG Groupings

When CPT 52346 is performed as an inpatient procedure, the case typically groups to one of the following MS-DRGs based on principal diagnosis and presence of complications/comorbidities:

Stone-Related DRGs (Most Common for CPT 52346)¹⁵

• DRG 693: Urinary Stones with MCC (Major Complications/Comorbidities)
  • Geometric mean LOS: 2.8 days
  • Relative weight: ~1.0849 (FY 2026)
  • National average payment: ~$6,000-7,000
  • Common scenarios: Stone with sepsis, renal failure, or other major comorbidity
• DRG 694: Urinary Stones without MCC
  • Geometric mean LOS: 2.0 days
  • Relative weight: ~0.6926 (FY 2026)
  • National average payment: ~$4,000-5,000
  • Common scenarios: Uncomplicated stone requiring ureteroscopy

Kidney and Ureter Procedure DRGs

• DRG 659: Kidney and Ureter Procedures for Non-Neoplasm with MCC
  • Geometric mean LOS: 5.1 days
  • Relative weight: ~2.3419
  • Higher payment: Major procedure with significant complications
• DRG 660: Kidney and Ureter Procedures for Non-Neoplasm with CC
  • Geometric mean LOS: 3.2 days
  • Relative weight: ~1.4072
• DRG 661: Kidney and Ureter Procedures for Non-Neoplasm without CC/MCC
  • Geometric mean LOS: 1.9 days
  • Relative weight: ~0.9679

Other Kidney and Urinary Tract DRGs

• DRG 673: Other Kidney and Urinary Tract Procedures with MCC
  • Geometric mean LOS: 4.5 days
  • Relative weight: ~2.0726
• DRG 674: Other Kidney and Urinary Tract Procedures with CC
  • Geometric mean LOS: 2.6 days
  • Relative weight: ~1.2181
• DRG 675: Other Kidney and Urinary Tract Procedures without CC/MCC
  • Geometric mean LOS: 1.7 days
  • Relative weight: ~0.8490

Diagnosis-Based DRGs (No Major Procedure)

• DRG 698: Other Kidney and Urinary Tract Diagnoses with MCC
• DRG 699: Other Kidney and Urinary Tract Diagnoses with CC
• DRG 700: Other Kidney and Urinary Tract Diagnoses without CC/MCC

Infection-Related DRGs

• DRG 689: Kidney and Urinary Tract Infections with MCC
  • When principal diagnosis is infection rather than stone/stricture
• DRG 690: Kidney and Urinary Tract Infections without MCC

IMPORTANT NOTES:

1. Outpatient procedures: Most CPT 52346 procedures are performed outpatient or in observation status, in which case MS-DRG does NOT apply. Payment is based on CPT code directly (physician fee schedule) or APC (Ambulatory Payment Classification) for facility.¹⁶

2. Principal diagnosis determines DRG: The principal diagnosis (reason for admission) drives DRG assignment, not the procedure performed.

3. CC/MCC impact: Presence of complications or comorbidities significantly affects DRG assignment and payment:

   • MCC (Major CC): Sepsis, acute kidney injury, respiratory failure, etc.
   • CC (Complication/Comorbidity): Diabetes, hypertension, COPD, etc.

Procedural Code Tree

50000-59999: Urinary System
└── 52000-52010: Endoscopy—Cystoscopy, Urethroscopy, Cystourethroscopy
    └── 52320-52356: Ureter and Pelvis Transurethral Surgical Procedures
        ├── 52341: Cystourethroscopy; with treatment of ureteral stricture
        ├── 52342: Cystourethroscopy; with treatment of UPJ stricture
        ├── 52343: Cystourethroscopy; with treatment of intra-renal stricture
        │
        ├── 52344: Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture
        ├── 52345: Cystourethroscopy with ureteroscopy; with treatment of UPJ stricture
        ├── 52346: Cystourethroscopy with ureteroscopy; with treatment of intra-renal stricture ◄ THIS CODE
        │
        ├── 52351: Cystourethroscopy with ureteroscopy and/or pyeloscopy; diagnostic
        ├── 52352: Cystourethroscopy with ureteroscopy; removal of stone
        ├── 52353: Cystourethroscopy with ureteroscopy; with lithotripsy
        ├── 52354: Cystourethroscopy with ureteroscopy; with biopsy and/or fulguration
        ├── 52355: Cystourethroscopy with ureteroscopy; with resection of tumor
        └── 52356: Cystourethroscopy with ureteroscopy; with lithotripsy of tumor

Related Codes:
├── 52000: Cystourethroscopy (diagnostic)
├── 52005: Cystourethroscopy with ureteral catheterization
├── 52332: Insertion of indwelling ureteral stent (add-on code)
└── 52334: Creation of ureterostomy, endoscopic

Code Differentiation

Key Distinction - With vs. Without Ureteroscopy:

• 52341-52343: WITHOUT ureteroscopy (cystoscope only, no advancement into ureter)
  • 52341: Ureteral stricture treatment
  • 52342: UPJ stricture treatment
  • 52343: Intra-renal stricture treatment
• 52344-52346: WITH ureteroscopy (scope advanced into ureter/kidney)
  • 52344: Ureteral stricture treatment WITH ureteroscopy
  • 52345: UPJ stricture treatment WITH ureteroscopy
  • 52346: Intra-renal stricture treatment WITH ureteroscopy ◄ THIS CODE

Location-Based Differentiation:

• Ureteral stricture (52341, 52344): Narrowing in the ureter itself
• UPJ stricture (52342, 52345): Narrowing at ureteropelvic junction (where ureter meets kidney)
• Intra-renal stricture (52343, 52346): Narrowing within the kidney (renal pelvis or calyx)¹⁷

Clinical Coding Examples

Example 1: Simple Right Intrarenal Stricture

Clinical Scenario: 58-year-old male with right flank pain and hydronephrosis. CT urogram shows infundibular stricture in right kidney upper pole calyx. Patient undergoes ureteroscopy with holmium laser incision of intrarenal stricture.

Operative Note Key Elements:

• Cystoscopy performed, normal bladder
• Right ureteral orifice identified
• Flexible ureteroscope advanced to right renal pelvis
• Upper pole infundibulum narrowed to 2mm
• Holmium laser used to incise stricture to 8mm
• No stent placed, patient voids well post-procedure

Coding:

• Primary procedure: 52346-RT
• Diagnosis: N13.39 (Other hydronephrosis, right kidney)
• Setting: Outpatient ASC
• Anesthesia: General anesthesia
• Payment: Facility ~$623,Professional$943

Rationale: Classic indication for 52346. Stricture is within kidney (intrarenal), ureteroscopy performed, laser treatment used. Right-side modifier required.¹⁸

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Example 2: Bilateral Intrarenal Strictures

Clinical Scenario: 45-year-old female with bilateral hydronephrosis due to bilateral UPJ and intrarenal strictures from prior instrumentation. Surgeon performs bilateral flexible ureteroscopy with balloon dilation of bilateral infundibular strictures.

Operative Note Key Elements:

• Bilateral cystoscopy performed
• Right ureteroscopy: Lower pole infundibular stricture balloon dilated from 3mm to 10mm
• Left ureteroscopy: Middle pole infundibular stricture balloon dilated from 2mm to 8mm
• Bilateral double-J stents placed

Coding (Medicare approach):

• Primary procedure: 52346-50 (1 unit)
• Stent placement: 52332-50 (1 unit, add-on code)
• Diagnosis: N13.39 (Bilateral other hydronephrosis)
• Payment: 150% for bilateral procedure

Coding (Commercial payer alternative):

• Line 1: 52346-RT
• Line 2: 52346-LT
• Line 3: 52332-RT
• Line 4: 52332-LT
• Diagnosis: N13.39

Note: Verify payer-specific bilateral coding requirements. Medicare prefers modifier 50 with 1 unit; some commercial payers prefer separate line items.¹⁹

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Example 3: Intrarenal Stricture with Stent Placement

Clinical Scenario: 62-year-old male with left hydronephrosis and intrarenal stricture. Ureteroscopy performed with electrocautery treatment of stricture, indwelling ureteral stent placed.

Operative Note Key Elements:

• Left cystoscopy and ureteroscopy
• Intrarenal stricture in renal pelvis narrowed to 4mm
• Electrocautery incision of stricture to 9mm
• 7Fr × 26cm double-J stent placed from kidney to bladder
• Stent position confirmed fluoroscopically

Coding:

• Primary procedure: 52346-LT
• Add-on procedure: 52332-LT
• Diagnosis: N13.30 (Unspecified hydronephrosis, left)
• Total payment: ~$770 facility (base + stent)

Rationale: 52332 is appropriately reported as an add-on when indwelling stent placed during ureteroscopy with stricture treatment. This is per CPT guidelines revised in 2014.²⁰

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Example 4: Failed Intrarenal Stricture Treatment

Clinical Scenario: Attempted right ureteroscopy for intrarenal stricture, but unable to advance scope past tight UPJ stricture. Procedure discontinued, patient scheduled for percutaneous approach.

Operative Note Key Elements:

• Cystoscopy performed
• Attempted right ureteroscopy
• Unable to pass ureteroscope beyond UPJ due to severe stricture
• Intrarenal stricture not reached
• Procedure discontinued
• Double-J stent placed to facilitate future procedure

Coding:

• Primary procedure: 52345-RT-53 (UPJ stricture treatment, discontinued)
• OR: 52334-RT-52 (stent creation, reduced service - if only stent placed)
• OR: 52332-RT (if simple stent placement without extensive manipulation)
• Diagnosis: N13.0 (Hydronephrosis with UPJ obstruction)

Rationale: Intrarenal stricture was NOT treated, so 52346 is inappropriate. Code what was actually done. Modifier 53 indicates discontinued procedure. Consider modifier 52 for reduced services if partial procedure completed.²¹

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Example 5: Intrarenal Stricture + Ureteral Stricture (Same Side)

Clinical Scenario: Patient with both mid-ureteral stricture and intrarenal calyceal stricture on right side. Surgeon treats both strictures during same session.

Operative Note Key Elements:

• Right ureteroscopy performed
• Mid-ureteral stricture balloon dilated 5mm to 12mm
• Scope advanced to kidney
• Upper pole infundibular stricture laser incised 3mm to 8mm
• Double-J stent placed

Coding:

• Primary procedure: 52346-RT (intrarenal stricture - higher RVU)
• Secondary procedure: 52344-RT-59 (ureteral stricture - needs modifier to unbundle)
• Stent: 52332-RT
• Diagnosis primary: N13.39 (intrarenal pathology)
• Diagnosis secondary: N13.1 (ureteral stricture)

Rationale: Two distinct anatomic sites treated (ureter AND intrarenal). Both codes appropriate with modifier 59 or XS on the component code (lower RVU) to indicate distinct service. NCCI edit exists between these codes but can be overridden with modifier when clinically appropriate.²²

NCCI Warning: Check current NCCI edits. 52344 and 52346 have Column 1/Column 2 relationship. Modifier required to report both. Ensure documentation clearly supports treatment of distinct anatomic sites.

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Example 6: Intrarenal Stricture with Assistant Surgeon

Clinical Scenario: Complex right intrarenal stricture in horseshoe kidney requiring assistant surgeon.

Operative Note Key Elements:

• Complex anatomy (horseshoe kidney)
• Surgeon and assistant surgeon both scrubbed
• Assistant maintained scope position while surgeon operated laser
• Assistant provided retraction and irrigation management
• Prolonged procedure time due to difficult anatomy

Primary Surgeon Coding:

• 52346-RT
• N13.39 (hydronephrosis)
• Q63.1 (horseshoe kidney - explains complexity)

Assistant Surgeon Coding:

• 52346-RT-80 (physician assistant)
• OR: 52346-RT-AS (PA, NP, or CNS)
• Same diagnoses
• Payment: 16% of primary surgeon fee (~$100)

Documentation Requirements:

• Assistant surgeon must document their active participation
• Describe specific assistance provided
• Explain why assistant was medically necessary (complex anatomy)
• Both providers must document in operative report²³

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Example 7: Intrarenal Stricture Treatment with Complication

Clinical Scenario: During treatment of left intrarenal stricture, ureteral perforation occurs. Surgeon places ureteral stent, patient admitted for observation.

Operative Note Key Elements:

• Left ureteroscopy for intrarenal stricture
• Laser incision of stricture
• Small perforation noted in proximal ureter during scope withdrawal
• Double-J stent placed across perforation site
• Patient admitted for overnight observation, antibiotics

Coding:

• Primary procedure: 52346-LT
• Stent: 52332-LT
• Diagnosis primary: N13.39 (hydronephrosis, original indication)
• Diagnosis complication: T83.89XA (Other complication of genitourinary device, initial)
• OR: N99.89 (Other postprocedural complications of genitourinary system)

DRG Assignment (inpatient admission):

• Likely DRG 673 or 674 (Other Kidney and Urinary Tract Procedures with MCC/CC)
• Complication may upgrade to MCC/CC level
• Higher payment than outpatient

Compliance Note: Perforation is a known risk of ureteroscopy. Document that it was recognized and appropriately managed. This is not a “never event” and should be coded accurately.²⁴

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Example 8: Diagnostic Ureteroscopy Converted to Therapeutic

Clinical Scenario: Scheduled diagnostic right ureteroscopy for hematuria. During procedure, intrarenal stricture discovered and treated.

Operative Note Key Elements:

• Initially planned as diagnostic ureteroscopy
• Right kidney visualized, source of bleeding identified as stricture
• Stricture causing mucosal trauma and bleeding
• Laser incision performed to relieve stricture
• Bleeding resolved
• Stent placed

Coding:

• Primary procedure: 52346-RT (therapeutic procedure)
• Stent: 52332-RT
• Diagnosis: R31.9 (Hematuria, unspecified) AND N13.39 (hydronephrosis)

Rationale: When diagnostic procedure is converted to therapeutic, code the therapeutic procedure. Do NOT separately code diagnostic ureteroscopy (52351) - it is bundled into the therapeutic code 52346.²⁵

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Example 9: Intrarenal Stricture in Transplant Kidney

Clinical Scenario: 55-year-old male with kidney transplant 3 years ago now with intrarenal stricture at anastomosis site. Ureteroscopy performed with balloon dilation.

Operative Note Key Elements:

• Patient with transplant kidney in right iliac fossa
• Cystoscopy performed
• Ureteral reimplantation site visualized
• Ureteroscopy to transplant kidney
• Intrarenal stricture at pelvi-ureteric junction dilated
• Stent placed

Coding:

• 52346-RT
• 52332-RT
• Diagnosis primary: N13.39 (hydronephrosis)
• Diagnosis secondary: Z94.0 (Kidney transplant status)
• Diagnosis tertiary: T86.19 (Other complication of kidney transplant) - if stricture is transplant-related complication

Special Considerations: Transplant kidney anatomy may be altered. Documentation should reflect modified approach. Some payers may have specific policies for transplant-related procedures.²⁶

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Example 10: Same-Day Bilateral Procedures, Different Pathology

Clinical Scenario: Patient with right intrarenal stricture and left ureteral stone. Both treated same session.

Operative Note Key Elements:

• Bilateral cystoscopy
• Right ureteroscopy: intrarenal stricture balloon dilated
• Left ureteroscopy: mid-ureteral stone laser lithotripsy
• Bilateral stents placed

Coding:

• 52346-RT (intrarenal stricture treatment)
• 52353-LT-59 (lithotripsy - distinct procedure, different pathology)
• 52332-50 (bilateral stent placement)
• Diagnosis right: N13.39
• Diagnosis left: N20.1 (ureteral calculus)

Rationale: Different procedures, different anatomic sites, different pathology. Both procedures separately reportable. Modifier 59 or XS on second procedure to indicate distinct service.²⁷

NCCI Edits and Bundling

Column 1/Column 2 Edits

52346 as Column 1 Code (Primary procedure - these are bundled INTO 52346):

• 52000: Cystourethroscopy (diagnostic) - Bundled, Modifier: 0
• 52005: Cystourethroscopy with ureteral catheterization - Bundled, Modifier: 0
• 52007: Cystourethroscopy with brush biopsy - Bundled, Modifier: 0
• 52351: Diagnostic ureteroscopy/pyeloscopy - Bundled, Modifier: 0
• 74420: Urography, retrograde - Bundled, Modifier: 0

52346 as Column 2 Code (These procedures include 52346 - cannot bill both):

• None - 52346 is not bundled into other codes as Column 2

Mutually Exclusive Edits

The following codes have NCCI edits with 52346 but CAN be reported together with appropriate modifier when distinct:

• 52344: Ureteroscopy with treatment of ureteral stricture
  • Edit: Column 1/Column 2 relationship
  • Modifier: 59, XS, or -XU allowed when distinct anatomic sites
  • Documentation: Must clearly show both ureteral AND intrarenal stricture treated
• 52345: Ureteroscopy with treatment of UPJ stricture
  • Edit: Column 1/Column 2 relationship
  • Modifier: 59, XS, or -XU allowed when distinct
  • Documentation: Must show both UPJ AND intrarenal stricture
• 52352: Ureteroscopy with removal of stone
  • Edit: May have NCCI edit
  • Modifier: 59, XS allowed when stone removal AND stricture treatment on different sides or clearly distinct procedures
• 52353: Ureteroscopy with lithotripsy
  • Edit: May have NCCI edit
  • Modifier: 59, XS allowed when distinct
  • Common scenario: Stone lithotripsy on one side, stricture treatment on other

Separately Reportable Add-On Code

• 52332: Insertion of indwelling ureteral stent
  • Status: SEPARATELY REPORTABLE as add-on
  • No modifier needed: Add-on codes exempt from NCCI edits
  • Payment: Full payment for stent placement in addition to 52346
  • CPT Guidelines: Per 2014 CPT revisions, 52332 may be reported in addition to 52344-52346 when self-retaining indwelling stent is placed²⁸

Common NCCI Mistakes to Avoid

1. Coding diagnostic ureteroscopy (52351) same side as therapeutic 52346

   • Error: Diagnostic work is bundled
   • Correct: Only code 52346

2. Coding cystoscopy (52000) same session as 52346

   • Error: Cystoscopy is bundled
   • Correct: Only code 52346

3. Failing to use modifier when coding 52344 + 52346 same side

   • Error: Claim will deny, both codes bundled without modifier
   • Correct: Use 59 or -XS if both ureteral AND intrarenal stricture treated

4. Coding bilateral with wrong methodology

   • Error: Using -50 for payers who require separate lines
   • Correct: Check payer policy (Medicare accepts -50, many commercial payers want -RT/-LT)

Key Coding Pearls

1. Laterality is mandatory: Always use RT, LT, or 50. Claims without laterality will be denied or delayed.

2. “Intra-renal” means inside the kidney: Stricture must be in renal pelvis, calix, or infundibulum. UPJ stricture is 52345, ureteral stricture is 52344.

3. Treatment method doesn’t matter for code selection: Whether balloon dilation, laser, electrocautery, or cold knife incision - all use the same code 52346. The code is based on LOCATION (intrarenal) not technique.

4. Ureteroscopy distinguishes 52346 from 52343:

   • 52343: Cystoscopy only, no ureteroscope advanced
   • 52346: Ureteroscopy performed with scope advanced into ureter/kidney
   • Higher RVU for 52346 reflects additional work

5. 52332 is separately reportable: When indwelling double-J stent placed after stricture treatment, code 52332 in addition to 52346. No modifier needed (add-on code).

6. Multiple strictures same side = one code: If treating multiple intrarenal strictures in same kidney during same session, report 52346 only once. Multiple areas of treatment are bundled.

7. Different anatomic sites = multiple codes:

   • Intrarenal stricture right + ureteral stricture right = 52346-RT + 52344-RT-59
   • Intrarenal stricture right + intrarenal stricture left = 52346-50 or 52346-RT + 52346-LT

8. Failed procedure coding: If intrarenal stricture not reached or not treated, do NOT code 52346. Code what was actually done (may be 52334, 52332, or unlisted code with modifier -52/-53).

9. Global period is 0 days: CPT 52346 has 0-day global period. Post-operative visits same day or next day are separately billable with E/M code + modifier -25.

10. Bilateral procedure payment:

    • Medicare: 150% payment (code once with modifier -50)
    • Some commercial: 100% + 50% payment (code twice with -RT/-LT)
    • Verify payer policy

11. Assistant surgeon documentation: When billing with -80/-AS, ensure operative report documents assistant’s role, necessity, and active participation throughout procedure.

12. Imaging is bundled: Fluoroscopy, ultrasound, or other imaging performed during the procedure is bundled into 52346. Do NOT separately code imaging S&I codes.

13. Pre-operative stent removal is bundled: If removing old stent at beginning of case before treating stricture, stent removal is bundled into 52346.

14. Contrast injection is bundled: Retrograde pyelography or contrast injection during procedure is bundled - do NOT code 50430 or 50431.

Documentation Requirements

Minimum Required Elements for CPT 52346

To support coding 52346, operative report must document:

1. Indication for procedure

   • Diagnosis (hydronephrosis, stricture, etc.)
   • Symptoms (pain, infection, renal dysfunction)
   • Imaging findings supporting stricture diagnosis

2. Laterality - CRITICAL

   • Right, left, or bilateral
   • Cannot be vague (“kidney”)

3. Cystourethroscopy performed

   • Visualization of bladder
   • Identification of ureteral orifice
   • Any bladder pathology noted

4. Ureteroscopy performed

   • Type of scope (rigid vs. flexible)
   • Advancement into ureter
   • Navigation to kidney
   • Visualization of renal pelvis/calyces

5. Location of stricture

   • Must be intrarenal (within kidney)
   • Specific location: renal pelvis, upper/mid/lower pole calyx, infundibulum
   • Size of stricture (diameter before treatment)

6. Treatment performed

   • Method used: balloon dilation, laser, electrocautery, cold knife
   • Equipment details (balloon size, laser settings, etc.)
   • Stricture caliber after treatment
   • Number of attempts or passes

7. Final outcome

   • Whether stricture successfully treated
   • Whether stent placed (if yes, size and type)
   • Whether nephrostomy placed
   • Patient condition at end

Enhanced Documentation for Optimal Reimbursement

8. Pre-procedure imaging

   • CT urogram, ultrasound, or IVP findings
   • Degree of hydronephrosis
   • Stone burden if present

9. Technical difficulty factors (if applicable)

   • Difficult anatomy (horseshoe kidney, ectopic kidney, transplant)
   • Previous surgery or scarring
   • Tortuous ureter
   • Multiple attempts required
   • Unusual positioning needs
   • Use of specialized equipment

10. Guidewire use

    • Type and size of guidewire
    • Successful passage beyond stricture
    • Safety wire placement

11. Fluoroscopic imaging

    • Fluoroscopy used for localization
    • Retrograde pyelography performed
    • Final stent position confirmed

12. Complications (if any)

    • Bleeding requiring intervention
    • Perforation and management
    • Stone migration
    • Equipment failure

13. Time elements (especially if modifier -22 considered)

    • Skin-to-skin time
    • Unusual length of procedure
    • Reason for extended time

Documentation Red Flags (Audit Risk)

• “Ureteroscopy performed” without describing scope advancement
• No mention of stricture location (just “renal stricture”)
• No laterality documented
• Vague treatment description (“stricture treated”)
• No mention of what type of scope used
• Conflicting information (e.g., says intrarenal but describes UPJ)
• Template language without patient-specific details
• No indication documented (why was procedure done?)

Coding from Incomplete Documentation

If documentation lacks required elements:

1. Query the physician for missing information
2. Do not assume: If laterality not stated, query before coding
3. Do not upcode: If unclear whether ureteroscopy performed, code lower-level 52343 instead of 52346
4. Document the query: Keep record of all queries and responses

Compliance Considerations

Medical Necessity Requirements

For CPT 52346 to be considered medically necessary:

1. Documented stricture confirmed by imaging (CT, ultrasound, retrograde pyelogram)

2. Clinical symptoms or complications from stricture:

   • Hydronephrosis
   • Pain
   • Infection
   • Declining renal function
   • Stone formation secondary to obstruction

3. Conservative management failed or not appropriate:

   • Stent trial did not resolve
   • Stricture too severe for observation
   • Urgent intervention required (infection, severe hydronephrosis)

4. Alternative therapies considered when appropriate:

   • Long-term stent management
   • Percutaneous approach
   • Open surgical repair

Payer-Specific Policies

Medicare:

• Medical necessity well-established for intrarenal strictures
• No prior authorization typically required
• Bilateral procedures paid at 150% with modifier -50
• Site of service: Outpatient ASC or HOPD preferred

Commercial Payers:

• May require prior authorization
• Check bilateral coding policy (modifier -50 vs. separate lines)
• Site of service restrictions may apply
• Some payers have step therapy requirements (trial of stenting first)

Medicaid:

• Varies by state
• Prior authorization often required
• May have preferred provider networks
• Documentation requirements may be more stringent

Audit Risk Areas

High-risk coding scenarios for 52346:

1. Frequent bilateral procedures: Unusually high percentage of bilateral cases may trigger review

2. Same patient, repeated procedures: Multiple ureteroscopies on same patient in short time frame

3. Modifier -22 overuse: Claiming increased complexity without strong documentation

4. Coding 52346 with 52344 or 52345 same side without clear documentation of distinct sites

5. High-volume providers: Providers performing 52346 at rates significantly above peers

6. Lack of imaging correlation: Coding stricture treatment without pre-operative imaging showing stricture

Summary

CPT 52346 represents an important endoscopic procedure in the urologist’s armamentarium for treating intrarenal strictures. The procedure combines cystourethroscopy with ureteroscopy and therapeutic intervention (balloon dilation, laser, electrocautery, or incision) to address narrowings within the kidney’s collecting system.

Key Points for Medical Coders:

• Active code with substantial work RVU (7.55) reflecting procedural complexity
• Laterality mandatory: Always use -RT, [-[LT]], or -50
• Location-specific: “Intra-renal” means within kidney (renal pelvis, calix, infundibulum)
• Ureteroscopy required: Distinguishes this from 52343 (cystoscopy-only approach)
• 52332 separately reportable: When indwelling stent placed, code as add-on
• Multiple treatment modalities included: Balloon, laser, electrocautery all use same code
• NCCI edits exist: Be aware of bundling with 52344, 52345, and diagnostic codes
• Assistant surgeon allowed: Indicator 2, payable at 16% with appropriate modifier
• Outpatient procedure: Most cases; inpatient admission groups to DRG 693/694 or 659-661
• Documentation critical: Must clearly state intrarenal location, ureteroscopy performed, treatment method, and outcome

For inpatient medical coders specializing in urology, this code represents a common therapeutic procedure for managing obstructive uropathy. Understanding the distinctions between 52344 (ureteral), 52345 (UPJ), and 52346 (intrarenal) is essential for accurate code assignment. When reviewing operative reports, pay close attention to the anatomic location of the stricture - this is the key determinant of code selection.

The relatively high work RVU reflects the technical skill required for flexible ureteroscopy, navigation of the intrarenal collecting system, and precise treatment of strictures in difficult-to-access locations. Assistant surgeon services are recognized as medically necessary in complex cases, and proper modifier use is essential for appropriate reimbursement.

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References

¹AMA CPT Professional Edition
²Case2Code CPT Reference
³AAPC Codify Cystourethroscopy Guidelines
⁴GenHealth Clinical Procedure Database
⁵CMS Physician Fee Schedule 2025
⁶CMS MPFS RVU Files
⁷CMS Assistant Surgeon Payment Policy Indicators
⁸AAPC Assistant Surgeon Guidelines
⁹AAPC Modifier Reference
¹⁰CPT Professional Component Guidelines
¹¹CPT Bundling Rules
¹²CPT 2014 Guideline Revisions Ureteroscopy
¹³AAPC NCCI Policy Manual
¹⁴CMS HCC Risk Adjustment Model
¹⁵CMS MS-DRG Definitions Manual v43.0
¹⁶CMS OPPS Payment Methodology
¹⁷CPT Surgical Procedure Code Tree
¹⁸AAPC Coding Clinic Ureteroscopy
¹⁹Medicare Bilateral Surgery Payment Rules
²⁰CPT Assistant Archives
²¹AAPC Modifier 52 and 53 Guidelines
²²NCCI Procedure to Procedure Edits
²³CMS Documentation Requirements Assistant Surgery
²⁴AAPC Complication Coding Guidelines
²⁵AAPC Diagnostic to Therapeutic Conversion
²⁶Transplant Procedure Coding Guidelines
²⁷NCCI Modifier Indicator Rules
²⁸CPT Editorial Panel Summary of Changes