52351

CPT 52351 - Cystourethroscopy with Ureteroscopy and/or Pyeloscopy; Diagnostic

Code Description

52351: Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic¹

This code describes a diagnostic endoscopic examination of the entire urinary collecting system performed transurethrally. The procedure combines cystourethroscopy (examination of the bladder and urethra), ureteroscopy (examination of the ureter), and/or pyeloscopy (examination of the renal pelvis and calyces) for diagnostic purposes only, without any therapeutic intervention.

Key Distinction: This is a diagnostic procedure code. When any therapeutic intervention is performed (stone removal, lithotripsy, biopsy, stricture treatment, tumor resection, etc.), a therapeutic code must be used instead of 52351.

Procedural Components

Cystourethroscopy

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

• Visualize the bladder mucosa
• Identify both ureteral orifices
• Assess for bladder pathology (tumors, inflammation, stones)
• Provide access for ureteroscope advancement²

Ureteroscopy

Advancement of a ureteroscope (rigid or flexible) through the ureteral orifice and up the ureter to:

• Visualize the ureteral mucosa
• Identify ureteral pathology (strictures, tumors, stones)
• Navigate to the renal pelvis
• Assess ureteral anatomy and caliber³

Pyeloscopy

Advancement of the scope into the renal pelvis and calyces to:

• Visualize the intrarenal collecting system
• Examine renal pelvis and calyces
• Identify intrarenal pathology (tumors, stones, anatomic variants)
• Assess for hydronephrosis or dilation

Important: The code descriptor states “and/or,” meaning the procedure may include ureteroscopy alone, pyeloscopy alone, or both. As long as the scope is advanced beyond the bladder into the upper urinary tract for diagnostic purposes, 52351 is appropriate.⁴

Work Relative Value Units (wRVU)

2025 Medicare Values

• Work RVU: 5.75⁵
• Facility PE RVU: 8.99
• Non-Facility PE RVU: 8.99
• Malpractice RVU: 0.90
• Total RVU (Facility): 15.64
• Total RVU (Non-Facility): 15.64

National Payment (2025 Conversion Factor: $32.35)

• Facility Setting: ~$506.05
• Non-Facility Setting: ~$506.05

Note: These values are national averages and subject to GPCI (Geographic Practice Cost Index) adjustments based on locality. Actual payment will vary by geographic location.⁶

RVU Context

The work RVU of 5.75 reflects:

• Time and complexity of navigating the ureter and renal pelvis
• Technical skill required for flexible ureteroscopy
• Risk of complications (perforation, bleeding, false passage creation)
• Comprehensive diagnostic evaluation of the upper urinary tract
• Need for precise endoscopic visualization and documentation

Comparison to Related Codes:

• 52000 (Diagnostic cystourethroscopy): 1.70 wRVU
• 52351 (Diagnostic ureteroscopy/pyeloscopy): 5.75 wRVU
• 52352 (Ureteroscopy with stone removal): 6.75 wRVU
• 52353 (Ureteroscopy with lithotripsy): 7.50 wRVU

The significantly higher RVU for 52351 versus simple cystoscopy reflects the additional work of navigating the ureter and intrarenal collecting system.⁷

Assistant Surgeon Information

Assistant Payable Status

Indicator: 1 (NOT allowed)⁸

This indicator means assistant surgeon services are NOT recognized as payable for this procedure. Medicare and most payers will deny assistant surgeon claims for CPT 52351.

Rationale: Diagnostic ureteroscopy is considered a procedure that:

• Can be safely performed by a single surgeon
• Does not require additional hands for completion
• Has relatively low complexity compared to major surgical procedures
• Is typically performed quickly without need for surgical assistance

Exception

In extraordinary circumstances (teaching hospitals, trainee participation, complex anatomy), an assistant may be present, but they cannot bill for their services under Medicare or most commercial payers.

Common Modifiers

Laterality Modifiers (MANDATORY)

• -50: Bilateral procedure
  • Use when procedure performed on both ureters/kidneys during same session
  • Payment: 150% of unilateral fee (Medicare)
• -RT: Right side
• -LT: Left side

CRITICAL: Laterality modifiers are required for CPT 52351. Claims submitted without appropriate laterality modifier may be denied or delayed.⁹

Distinct Procedural Service Modifiers

• -59: Distinct procedural service
  • Rarely needed with 52351
  • May be used when performed at separate session from another procedure
• -XS: Separate structure (X-modifier subset)
  • Use for bilateral coding with some payers
• -XE: Separate encounter
  • Different operative session same day
• -XP: Separate practitioner
  • Different physician performing procedure

Reduction/Conversion Modifiers

• -22: Increased procedural services
  • Use for unusually complex anatomy (horseshoe kidney, duplicated collecting system)
  • Requires detailed documentation
  • Additional payment: 20-30% (varies by payer)
• -52: Reduced services
  • Use when procedure partially performed
  • Example: Unable to advance scope to renal pelvis, only ureter visualized
  • Payment reduced proportionally
• -53: Discontinued procedure
  • Use when procedure started but stopped before completion
  • Example: Severe ureteral stricture prevents scope advancement
  • Document reason for discontinuation
• -76: Repeat procedure by same physician (same day)
• -77: Repeat procedure by different physician (same day)

Multiple Procedure Modifier

• -51: Multiple procedures
  • Used when 52351 performed with other non-bundled procedures
  • Typically applies to second and subsequent procedures
  • Many payers automatically apply this logic

Note: -26 (Professional component) and -TC (Technical component) are NOT applicable. CPT 52351 is a surgical procedure code without separate professional/technical components.¹⁰

Includes

The following are bundled into CPT 52351 and should NOT be separately coded:

1. Cystourethroscopy (diagnostic bladder examination)
2. Ureteral catheterization (for guidewire placement, contrast injection)
3. Retrograde pyelography (if performed as part of diagnostic evaluation)
4. Fluoroscopic guidance (if used during procedure)
5. Contrast material injection for visualization
6. Multiple attempts at scope advancement
7. Examination of ureter (full length)
8. Examination of renal pelvis and calyces (if reached)
9. Photography or video recording of findings
10. Any diagnostic visualization performed during the procedure¹¹

Excludes

The following procedures are NOT bundled and may be separately reportable:

Therapeutic Procedures (Substitute 52351 with appropriate therapeutic code)

When ANY therapeutic intervention is performed, 52351 is NOT coded. Use the specific therapeutic code instead:

• 52352: Stone removal or manipulation (replaces 52351)
• 52353: Lithotripsy (replaces 52351)
• 52354: Biopsy and/or fulguration (replaces 52351)
• 52355: Tumor resection (replaces 52351)
• 52344: Ureteral stricture treatment (replaces 52351)
• 52345: UPJ stricture treatment (replaces 52351)
• 52346: Intrarenal stricture treatment (replaces 52351)

CRITICAL CODING RULE: Diagnostic ureteroscopy (52351) is bundled into ALL therapeutic ureteroscopy procedures. When a therapeutic procedure is performed, code ONLY the therapeutic procedure, NOT both.¹²

Separately Reportable Add-on Code

• 52332: Insertion of indwelling ureteral stent (eg, Gibbons or double-J type)
  • Report separately when stent placed after diagnostic ureteroscopy
  • Per CPT guidelines (revised 2014), 52332 may be reported in addition to 52351
  • Payment: Full payment for stent in addition to 52351
  • No modifier needed: Add-on codes are exempt from NCCI edits
  • Most common add-on: 52351-RT + 52332-RT¹³

Different Session Procedures

• Procedures performed at different operative session same day may be separately reportable with modifier 76 or 77

Common Associated Diagnoses (ICD-10-CM)

Hematuria (Most Common Indication for Diagnostic Ureteroscopy)

Gross Hematuria:

• R31.0: Gross hematuria
  • HCC: No
  • Clinical: Visible blood in urine
  • Indication: Primary indication for diagnostic ureteroscopy

Microscopic Hematuria:

• R31.1: Benign essential microscopic hematuria
  • HCC: No
  • Clinical: Microscopic blood without pathologic cause
• R31.21: Asymptomatic microscopic hematuria
  • HCC: No
  • Clinical: Incidental finding on urinalysis
• R31.29: Other microscopic hematuria
  • HCC: No
  • Clinical: Persistent microscopic hematuria requiring evaluation

Unspecified:

• R31.9: Hematuria, unspecified
  • HCC: No
  • Clinical: Use when gross vs microscopic not documented

Hydronephrosis / Obstruction Codes

• N13.0: Hydronephrosis with ureteropelvic junction obstruction
  • HCC: May contribute to HCC 138 (CKD Stage 3-4) if CKD documented
  • Clinical: UPJ obstruction causing kidney swelling
• N13.1: Hydronephrosis with ureteral stricture, not elsewhere classified
  • HCC: May contribute to HCC 138 if CKD present
  • Clinical: Ureteral narrowing with kidney swelling
• N13.2: Hydronephrosis with renal and ureteral calculous obstruction
  • HCC: May contribute to HCC 138 if CKD documented
  • Clinical: Stone causing obstruction and hydronephrosis
• N13.30: Unspecified hydronephrosis
  • HCC: May contribute to HCC 138
  • Clinical: Use when cause not specified
• N13.39: Other hydronephrosis
  • HCC: May contribute to HCC 138
  • Clinical: Hydronephrosis from other specified causes

Calculus/Stone Disease

• N20.0: Calculus of kidney
  • HCC: No
  • Clinical: Nephrolithiasis
• N20.1: Calculus of ureter
  • HCC: No
  • Clinical: Ureteral stone
  • Common: Diagnostic ureteroscopy to visualize/assess stone
• N20.2: Calculus of kidney with calculus of ureter
  • HCC: No
  • Clinical: Bilateral or multiple stones

Suspected or Known Malignancy

• C64.1: Malignant neoplasm of right kidney, except renal pelvis

  • HCC: HCC 11 (Colorectal, Bladder, and Other Cancers)
  • RAF: Significant risk adjustment impact

• C64.2: Malignant neoplasm of left kidney, except renal pelvis

  • HCC: HCC 11

• C64.9: Malignant neoplasm of unspecified kidney, except renal pelvis

  • HCC: HCC 11
  • Use: When laterality not documented

• C65.1: Malignant neoplasm of right renal pelvis

  • HCC: HCC 11

• C65.2: Malignant neoplasm of left renal pelvis

  • HCC: HCC 11

• C65.9: Malignant neoplasm of unspecified renal pelvis

  • HCC: HCC 11

• C66.1: Malignant neoplasm of right ureter

  • HCC: HCC 11

• C66.2: Malignant neoplasm of left ureter

  • HCC: HCC 11

• C66.9: Malignant neoplasm of unspecified ureter

  • HCC: HCC 11

• C67.9: Malignant neoplasm of bladder, unspecified

  • HCC: HCC 11
  • Clinical: May have upper tract involvement

• D41.11: Neoplasm of uncertain behavior of right renal pelvis

  • HCC: No
  • Clinical: Transitional cell carcinoma, uncertain malignant potential

• D41.12: Neoplasm of uncertain behavior of left renal pelvis

  • HCC: No

• D41.21: Neoplasm of uncertain behavior of right ureter

  • HCC: No

• D41.22: Neoplasm of uncertain behavior of left ureter

  • HCC: No

Urinary Symptoms

• R30.0: Dysuria
  • HCC: No
  • Clinical: Painful urination
• R33.8: Other retention of urine
  • HCC: No
  • Clinical: Urinary retention
• R35.0: Frequency of micturition
  • HCC: No
  • Clinical: Urinary frequency
• R39.0: Extravasation of urine
  • HCC: No
  • Clinical: Urine leak (suggests perforation or fistula)
• R39.12: Poor urinary stream
  • HCC: No
  • Clinical: Weak stream suggesting obstruction
• R39.15: Urgency of urination
  • HCC: No
  • Clinical: Urinary urgency
• R39.9: Unspecified symptoms and signs involving the genitourinary system
  • HCC: No
  • Use: Nonspecific urinary complaints

Infection

• N10: Acute pyelonephritis
  • HCC: No
  • Clinical: Acute kidney infection
  • Use additional code: B95-B97 for organism if known
• N11.1: Chronic obstructive pyelonephritis
  • HCC: May contribute depending on severity
  • Clinical: Chronic infection with obstruction
• N30.00: Acute cystitis without hematuria
  • HCC: No
  • Clinical: Bladder infection
• N30.01: Acute cystitis with hematuria
  • HCC: No
  • Clinical: Bladder infection with blood in urine

Anatomic Abnormalities

• Q62.0: Congenital hydronephrosis
  • HCC: No
  • Clinical: Present from birth
• Q62.11: Congenital occlusion of ureteropelvic junction
  • HCC: No
  • Clinical: Congenital UPJ obstruction
• Q62.31: Congenital ureterocele
  • HCC: No
  • Clinical: Cystic dilation of distal ureter
• Q63.1: Lobulated, fused and horseshoe kidney
  • HCC: No
  • Clinical: Horseshoe kidney (increases procedural complexity)

Post-Procedural/Stent-Related

• Z96.0: Presence of urogenital implants
  • HCC: No
  • Clinical: Stent in place
  • Use: For stent checks or follow-up
• Z43.6: Encounter for attention to other artificial openings of urinary tract
  • HCC: No
  • Clinical: Stent management
• T83.112A: Breakdown (mechanical) of indwelling ureteral stent, initial encounter
  • HCC: No
  • Clinical: Stent malfunction
  • 7th character: A (initial), D (subsequent), S (sequela)
• T83.192A: Other mechanical complication of indwelling ureteral stent, initial
  • HCC: No
  • Clinical: Other stent complications

HCC Summary: Most indications for diagnostic ureteroscopy do NOT directly map to HCCs unless malignancy or advanced CKD is documented. Malignancy diagnoses (C64, C65, C66) map to HCC 11 with significant risk adjustment impact.¹⁴

MS-DRG Groupings

When CPT 52351 is performed as an inpatient procedure, the case typically groups based on principal diagnosis rather than the procedure itself:

Stone-Related DRGs¹⁵

• DRG 693: Urinary Stones with MCC
  • Geometric mean LOS: 2.8 days
  • Relative weight: ~1.08
  • Note: Diagnostic procedure unlikely to drive DRG assignment
• DRG 694: Urinary Stones without MCC
  • Geometric mean LOS: 2.0 days
  • Relative weight: ~0.69

Diagnosis-Based DRGs (More Common for Diagnostic Procedures)

• 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

IMPORTANT NOTES:

1. Outpatient procedures: CPT 52351 is almost always 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. Diagnostic procedures: Diagnostic ureteroscopy rarely justifies inpatient admission unless:

   • Performed in conjunction with other procedures
   • Patient has significant comorbidities
   • Sepsis or acute infection present
   • High-risk patient requiring monitoring

3. APC Assignment (Outpatient facility payment):

   • APC 5374 or similar
   • Much more common than DRG assignment for 52351

Procedural Code Tree

50000-59999: Urinary System
└── 52000-52010: Endoscopy—Cystoscopy, Urethroscopy, Cystourethroscopy
    └── 52320-52356: Ureter and Pelvis Transurethral Surgical Procedures
        │
        ├── DIAGNOSTIC PROCEDURES:
        │   └── 52351: Cystourethroscopy with ureteroscopy and/or pyeloscopy; diagnostic ◄ THIS CODE
        │
        ├── THERAPEUTIC STONE PROCEDURES:
        │   ├── 52352: With removal or manipulation of calculus
        │   ├── 52353: With lithotripsy
        │   └── 52356: With lithotripsy including insertion of indwelling stent
        │
        ├── THERAPEUTIC TISSUE PROCEDURES:
        │   ├── 52354: With biopsy and/or fulguration of ureteral or renal pelvic lesion
        │   └── 52355: With resection of ureteral or renal pelvic tumor
        │
        └── THERAPEUTIC STRICTURE PROCEDURES:
            ├── 52344: With treatment of ureteral stricture
            ├── 52345: With treatment of UPJ stricture
            └── 52346: With treatment of intra-renal stricture

Supporting Codes:
├── 52000: Cystourethroscopy (diagnostic, bladder only)
├── 52005: Cystourethroscopy with ureteral catheterization
├── 52007: Cystourethroscopy with brush biopsy
└── 52332: Insertion of indwelling ureteral stent (add-on code)

Critical Coding Distinction

The fundamental rule: 52351 is for DIAGNOSTIC ureteroscopy/pyeloscopy ONLY.

If ANY therapeutic intervention is performed:

• Stone removal → Code 52352, NOT 52351
• Lithotripsy → Code 52353, NOT 52351
• Biopsy → Code 52354, NOT 52351
• Tumor resection → Code 52355, NOT 52351
• Stricture treatment → Code 52344/52345/52346, NOT 52351

Exception: Stent placement (52332) can be coded in addition to 52351 if no other therapeutic intervention is performed.¹⁷

Clinical Coding Examples

Example 1: Simple Diagnostic Right Ureteroscopy

Clinical Scenario: 45-year-old female with right flank pain and microhematuria. Imaging shows possible right ureteral filling defect. Diagnostic ureteroscopy performed to evaluate.

Operative Note Key Elements:

• Cystoscopy performed, normal bladder
• Right ureteral orifice identified
• Flexible ureteroscope advanced to right renal pelvis
• No stones, masses, or strictures identified
• Normal appearing urothelium throughout
• Scope removed, patient tolerated well

Coding:

• Primary procedure: 52351-RT
• Diagnosis: R31.1 (Benign essential microscopic hematuria)
• Setting: Outpatient ASC
• Payment: ~$506

Rationale: Pure diagnostic procedure, no therapeutic intervention, no stent placed.¹⁸

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Example 2: Diagnostic Ureteroscopy with Stent Placement

Clinical Scenario: 52-year-old male with left hydronephrosis of unknown etiology. Diagnostic ureteroscopy reveals narrowed ureter but no stone or tumor. Stent placed to maintain drainage while awaiting further evaluation.

Operative Note Key Elements:

• Left cystourethroscopy normal
• Flexible ureteroscopy advanced to left renal pelvis
• Diffuse ureteral narrowing noted, no discrete stricture
• Renal pelvis dilated, no masses or stones
• 7Fr x 26cm double-J stent placed from kidney to bladder
• Stent position confirmed fluoroscopically

Coding:

• Primary procedure: 52351-LT
• Add-on procedure: 52332-LT
• Diagnosis: N13.30 (Unspecified hydronephrosis, left)
• Payment: ~$506+$150 = ~$656

Rationale: Diagnostic ureteroscopy with stent placement. No therapeutic intervention on pathology (no stone removal, no biopsy, no stricture treatment), so 52351 appropriate. 52332 separately reportable per 2014 CPT guidelines.¹⁹

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Example 3: Bilateral Diagnostic Ureteroscopy

Clinical Scenario: 60-year-old female with bilateral hydronephrosis. Bilateral diagnostic ureteroscopy performed to evaluate for obstruction or malignancy.

Operative Note Key Elements:

• Bilateral cystoscopy performed
• Right ureteroscopy: Normal ureter and renal pelvis, no pathology
• Left ureteroscopy: Normal ureter and renal pelvis, no pathology
• Bilateral hydronephrosis confirmed but no obstructing lesion identified

Coding (Medicare approach):

• Primary procedure: 52351-50 (1 unit)
• Diagnosis: N13.30 (Unspecified hydronephrosis, bilateral)
• Payment: 150% = ~$759

Coding (Commercial payer alternative):

• Line 1: 52351-RT
• Line 2: 52351-LT
• Diagnosis: N13.30

Note: Check payer-specific bilateral coding requirements.²⁰

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Example 4: Diagnostic Ureteroscopy Converted to Therapeutic (WRONG CODING)

Clinical Scenario: Scheduled diagnostic right ureteroscopy for hematuria. During procedure, small 3mm ureteral stone discovered and basketed out.

Operative Note Key Elements:

• Initially planned as diagnostic ureteroscopy
• Right ureteroscopy performed
• 3mm stone identified in distal ureter
• Stone successfully basketed and removed
• No stent placed

INCORRECT Coding:

• 52351-RT (diagnostic ureteroscopy)
• 52352-RT (stone removal)

CORRECT Coding:

• Primary procedure ONLY: 52352-RT
• Diagnosis: N20.1 (Calculus of ureter, right)

Rationale: When a therapeutic procedure is performed, code ONLY the therapeutic procedure. Diagnostic ureteroscopy (52351) is bundled into 52352. Do NOT code both. This is a common NCCI edit violation.²¹

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Example 5: Failed Diagnostic Ureteroscopy

Clinical Scenario: Attempted left diagnostic ureteroscopy for suspected ureteral tumor. Unable to advance scope past tight mid-ureteral stricture. Procedure discontinued, patient scheduled for percutaneous approach.

Operative Note Key Elements:

• Left cystoscopy performed
• Attempted left ureteroscopy
• Unable to pass ureteroscope beyond mid-ureter due to severe stricture
• Renal pelvis not visualized
• Procedure discontinued
• Plan for antegrade percutaneous approach

Coding:

• Primary procedure: 52351-LT-53 (discontinued procedure)
• OR: 52000-LT-52 (if only cystoscopy completed)
• Diagnosis: N13.1 (Hydronephrosis with ureteral stricture, left)

Rationale: Ureteroscopy attempted but not completed. Modifier 53 indicates discontinued procedure. Alternative is to code only what was accomplished (52000 for cystoscopy) with modifier 52 for reduced services. Documentation should clearly explain why procedure was discontinued.²²

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Example 6: Diagnostic Ureteroscopy in Patient with Known Upper Tract TCC

Clinical Scenario: 68-year-old male with history of right renal pelvis transitional cell carcinoma (TCC), status post laser ablation 6 months ago. Surveillance ureteroscopy performed to assess for recurrence.

Operative Note Key Elements:

• Right cystoscopy normal
• Flexible ureteroscopy to right renal pelvis
• No evidence of tumor recurrence
• Renal pelvis and calyces free of lesions
• Ureteral mucosa normal

Coding:

• 52351-RT
• Diagnosis: Z08 (Encounter for follow-up examination after completed treatment for malignant neoplasm)
• Secondary diagnosis: Z85.528 (Personal history of other malignant neoplasm of renal pelvis)

Rationale: Surveillance ureteroscopy is diagnostic. No biopsy or treatment performed. Use Z-codes for cancer surveillance.²³

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Example 7: Same-Day Repeat Ureteroscopy (Equipment Failure)

Clinical Scenario: Right diagnostic ureteroscopy performed. During procedure, flexible ureteroscope malfunctions. Procedure completed with second scope same operative session.

Operative Note Key Elements:

• Right ureteroscopy initiated
• Scope malfunction during procedure
• Scope exchanged for backup scope
• Procedure completed successfully with second scope
• Diagnostic evaluation completed

Coding:

• 52351-RT (code once only)
• Diagnosis: R31.0 (Gross hematuria)

Do NOT code: 52351-RT twice or with modifier 76/77

Rationale: Multiple attempts during same operative session are bundled into single code. Code the procedure once regardless of number of scope insertions or equipment changes.²⁴

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Example 8: Diagnostic Ureteroscopy with Retrograde Pyelography

Clinical Scenario: Left diagnostic ureteroscopy with retrograde pyelogram performed to evaluate hydronephrosis.

Operative Note Key Elements:

• Left cystoscopy performed
• Ureteral catheter advanced to renal pelvis
• Contrast injected under fluoroscopy
• Retrograde pyelogram obtained showing dilated collecting system
• Flexible ureteroscope advanced to renal pelvis
• Direct visualization confirmed dilation, no obstructing lesion

Coding:

• 52351-LT
• Diagnosis: N13.30 (Unspecified hydronephrosis, left)

Do NOT separately code:

• 50430 or 50431 (retrograde pyelography)
• 74420 (urography supervision and interpretation)

Rationale: Retrograde pyelography performed as part of diagnostic ureteroscopy is bundled into 52351. Do not separately code contrast injection or imaging S&I.²⁵

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Example 9: Diagnostic Ureteroscopy in Horseshoe Kidney

Clinical Scenario: 55-year-old male with horseshoe kidney and right flank pain. Diagnostic ureteroscopy performed; procedure significantly more difficult due to altered anatomy.

Operative Note Key Elements:

• Right cystoscopy, horseshoe kidney configuration noted
• Ureteral orifice located more laterally than normal
• Difficult ureteroscope advancement due to acute angle
• Multiple repositioning attempts required
• Flexible ureteroscope eventually advanced to renal pelvis
• Procedure time 45 minutes (typical 15-20 minutes)
• No pathology identified

Coding:

• 52351-RT-22
• Diagnosis primary: R31.0 (Gross hematuria)
• Diagnosis secondary: Q63.1 (Horseshoe kidney)

Documentation: Detailed operative note explaining increased complexity, time, and technical difficulty due to horseshoe kidney anatomy. Modifier 22 indicates increased procedural services, may warrant 20-30% additional payment.²⁶

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Example 10: Bilateral Diagnostic Ureteroscopy, Unilateral Stent

Clinical Scenario: Bilateral diagnostic ureteroscopy performed. Left ureter narrow but passable; stent placed on left only for post-procedure drainage.

Operative Note Key Elements:

• Bilateral cystoscopy performed
• Right ureteroscopy: Normal caliber ureter and renal pelvis
• Left ureteroscopy: Narrowed ureter, successfully navigated to renal pelvis
• Left stent (7Fr x 26cm) placed for drainage
• Right side no stent needed

Coding:

• 52351-50 (bilateral diagnostic ureteroscopy)
• 52332-LT (left ureteral stent only)
• Diagnosis: N13.30 (Hydronephrosis)

Alternative coding (some payers):

• 52351-RT
• 52351-LT
• 52332-LT

Note: Stent coded only for left side where placed. Do not code 52332 bilaterally when stent placed only unilaterally.²⁷

NCCI Edits and Bundling

Column 1/Column 2 Edits

52351 as Column 1 Code (Primary procedure - these are bundled INTO 52351):

• 52000: Cystourethroscopy (diagnostic) - Bundled, Modifier: 0
• 52005: Cystourethroscopy with ureteral catheterization - Bundled, Modifier: 0
• 52007: Cystourethroscopy with brush biopsy of ureter/renal pelvis - Bundled, Modifier: 1
• 50430: Injection for nephrostogram, new access - Bundled, Modifier: 0
• 50431: Injection for nephrostogram, existing access - Bundled, Modifier: 0
• 74420: Urography, retrograde - Bundled, Modifier: 0

52351 as Column 2 Code (These procedures INCLUDE 52351 - cannot bill both):

• 52352: Ureteroscopy with stone removal - 52351 bundled, Modifier: 0
• 52353: Ureteroscopy with lithotripsy - 52351 bundled, Modifier: 0
• 52354: Ureteroscopy with biopsy/fulguration - 52351 bundled, Modifier: 0
• 52355: Ureteroscopy with tumor resection - 52351 bundled, Modifier: 0
• 52356: Ureteroscopy with lithotripsy + stent - 52351 bundled, Modifier: 0
• 52344: Ureteroscopy with ureteral stricture treatment - 52351 bundled, Modifier: 0
• 52345: Ureteroscopy with UPJ stricture treatment - 52351 bundled, Modifier: 0
• 52346: Ureteroscopy with intrarenal stricture treatment - 52351 bundled, Modifier: 0

Critical Understanding: The NCCI edits reflect the core CPT principle that diagnostic procedures are bundled into therapeutic procedures. When ANY therapeutic work is done during ureteroscopy, 52351 cannot be coded.²⁸

Separately Reportable Add-on Code

• 52332: Insertion of indwelling ureteral stent
  • Status: SEPARATELY REPORTABLE with 52351
  • No modifier needed: Add-on codes exempt from NCCI
  • Payment: Full payment for stent in addition to diagnostic ureteroscopy
  • 2014 CPT change: 52332 explicitly allowed with diagnostic ureteroscopy codes

Common NCCI Mistakes to Avoid

1. Coding 52351 with therapeutic code same side

   • Error: 52351-RT + 52352-RT
   • Correct: 52352-RT only
   • Why: Diagnostic work bundled into therapeutic procedure

2. Coding retrograde pyelography separately

   • Error: 52351-RT + 50430-RT
   • Correct: 52351-RT only
   • Why: Retrograde pyelography bundled into ureteroscopy

3. Coding cystoscopy separately same session

   • Error: 52000 + 52351-RT
   • Correct: 52351-RT only
   • Why: Cystoscopy is inherent to ureteroscopy

4. Forgetting laterality modifier

   • Error: 52351 (no modifier)
   • Correct: 52351-RT or 52351-LT
   • Why: Laterality required for proper payment

Key Coding Pearls

1. Diagnostic ONLY: 52351 is for diagnostic ureteroscopy without any therapeutic intervention. Any stone removal, biopsy, lithotripsy, or stricture treatment = use therapeutic code instead.

2. 52332 is separately reportable: When stent placed after diagnostic ureteroscopy with no other therapeutic intervention, code 52351 + 52332. This is an exception to the “diagnostic bundled into therapeutic” rule.

3. Laterality is mandatory: Always use RT, LT, or 50. Missing laterality = claim denial.

4. Cystoscopy is bundled: Do NOT separately code 52000 or 52005 when performing 52351. Cystoscopy is inherent to the procedure.

5. Retrograde pyelography is bundled: Do NOT separately code 50430, 50431, or 74420 when performed during ureteroscopy.

6. “And/or” means flexibility: The code descriptor says “ureteroscopy and/or pyeloscopy” - you can code 52351 for ureteroscopy alone, pyeloscopy alone, or both. As long as scope advances beyond bladder into upper tract.

7. Failed procedure considerations: If unable to complete ureteroscopy (can’t advance scope), consider modifier 52 or 53, or code only what was accomplished (52000 for cystoscopy only).

8. Converted procedures: If diagnostic procedure is converted to therapeutic during same session, code ONLY the therapeutic procedure. Example: Went in for diagnostic look, found and removed stone = 52352 only, NOT 52351 + 52352.

9. Global period is 0 days: CPT 52351 has 0-day global period. Post-operative E/M visits are separately billable with modifier 25 if performed same day or next day.

10. Assistant surgeon NOT allowed: Indicator 1 means no assistant surgeon payment. Even if assistant is present, they cannot bill Medicare or most commercial payers.

11. Bilateral coding varies by payer:

    • Medicare: Modifier 50, 1 unit, 150% payment
    • Some commercial: Separate lines with RT/LT, 100% + 50%
    • Always verify payer policy

12. Surveillance ureteroscopy: For cancer surveillance, use appropriate Z-codes (Z08, Z85.xxx) as primary diagnosis.

13. Equipment failure: Multiple scope insertions due to equipment malfunction during same session = code once only. Do NOT code multiple units.

14. Documentation is critical: Operative note must clearly state:

    • Diagnostic intent
    • No therapeutic intervention performed
    • What was visualized (ureter, renal pelvis, calyces)
    • Findings (normal vs abnormal anatomy)
    • Whether stent placed

Documentation Requirements

Minimum Required Elements for CPT 52351

To support coding 52351, operative report must document:

1. Indication for procedure

   • Diagnosis (hematuria, hydronephrosis, suspected tumor, etc.)
   • Symptoms prompting evaluation
   • Prior imaging findings

2. Laterality - CRITICAL

   • Right, left, or bilateral
   • Cannot be vague

3. Cystourethroscopy performed

   • Visualization of bladder
   • Description of bladder appearance
   • Identification of ureteral orifice(s)

4. Ureteroscopy performed

   • Type of scope used (rigid vs. flexible)
   • Advancement into ureter
   • Extent of advancement (to renal pelvis, calyces)
   • Description of ureteral appearance

5. Pyeloscopy (if performed)

   • Visualization of renal pelvis
   • Examination of calyces
   • Description of intrarenal findings

6. Findings

   • Normal vs. abnormal anatomy
   • Presence or absence of:
     • Stones
     • Masses/tumors
     • Strictures
     • Inflammation
     • Other pathology

7. Diagnostic nature confirmed

   • Statement that “no therapeutic intervention performed”
   • OR specific mention of what therapeutic procedure WAS done (which would change the code)

8. Stent placement (if applicable)

   • Size and type of stent
   • Position (renal pelvis to bladder)
   • Fluoroscopic confirmation

Enhanced Documentation for Optimal Reimbursement

9. Guidewire use

   • Type and size of guidewire
   • Successful advancement to renal pelvis
   • Safety wire maintained throughout

10. Fluoroscopic imaging

    • Fluoroscopy used for visualization
    • Retrograde pyelogram performed (if done)
    • Images obtained and reviewed

11. Technical difficulty factors (for modifier 22 consideration)

    • Anatomic variants (horseshoe kidney, duplicated collecting system, ectopic kidney)
    • Previous surgery or scarring
    • Tortuous ureter
    • Multiple attempts required
    • Unusual patient positioning
    • Extended procedure time with explanation

12. Patient tolerance

    • Procedure completed without complication
    • Patient tolerated procedure well
    • Vital signs stable

13. Post-procedure plan

    • Follow-up imaging
    • Further procedures planned
    • Stent removal schedule (if stent placed)

Documentation Red Flags (Audit Risk)

• “Ureteroscopy performed” without describing what was visualized
• No mention of findings (must state normal vs. abnormal)
• No laterality documented anywhere in report
• Vague therapeutic language (“ureteral dilation performed” - if true, should code 52344 not 52351)
• Stone mentioned but not addressed (if stone seen, was it removed? If yes = 52352, not 52351)
• Biopsy mentioned but not coded (if biopsy taken = 52354, not 52351)
• Conflicting information (e.g., “diagnostic ureteroscopy” in title but “stone basketed” in body)
• Template language without patient-specific details
• Missing indication (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 anything therapeutic was done, query physician
4. Document the query: Keep record of all queries and responses
5. Code conservatively: When in doubt, code lower-level procedure or cystoscopy only (52000)

Compliance Considerations

Medical Necessity Requirements

For CPT 52351 to be considered medically necessary:

1. Appropriate indication documented:

   • Hematuria (gross or microscopic)
   • Hydronephrosis of unknown cause
   • Suspected upper tract malignancy
   • Follow-up surveillance for known TCC
   • Ureteral obstruction etiology unclear
   • Suspected anatomic abnormality
   • Recurrent UTI with upper tract concerns

2. Prior imaging usually expected:

   • CT urogram
   • Ultrasound
   • IVP (intravenous pyelogram)
   • Retrograde pyelogram
   • Note: Imaging not always required for hematuria workup

3. Failed or inadequate non-invasive workup:

   • Imaging inconclusive
   • Need for tissue diagnosis
   • Need for direct visualization

Payer-Specific Policies

Medicare:

• Medical necessity well-established for hematuria, hydronephrosis, suspected malignancy
• No prior authorization typically required for diagnostic ureteroscopy
• National Coverage Determination (NCD) and Local Coverage Determination (LCD) may apply
• Frequency limitations may apply for surveillance ureteroscopy

Commercial Payers:

• May require prior authorization
• Check bilateral coding policy (modifier 50 vs. separate lines)
• Some payers have specific medical necessity criteria
• Frequency limitations for surveillance procedures

Medicaid:

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

Audit Risk Areas

High-risk coding scenarios for 52351:

1. High-volume providers: Performing 52351 at rates significantly above peers

2. 52351 followed by 52352-52356 on follow-up: Pattern of diagnostic procedure followed by therapeutic procedure shortly after (suggests diagnostic procedure may not have been necessary)

3. Frequent bilateral procedures: Unusually high percentage of bilateral cases

4. Same patient, repeated procedures: Multiple diagnostic ureteroscopies on same patient in short time frame without clear indication

5. Coding with therapeutic codes same side: 52351-RT + 52352-RT = red flag for bundling violation

6. Missing or vague documentation: Operative notes that don’t clearly support diagnostic vs. therapeutic nature

Fraud and Abuse Concerns

Upcoding: Coding 52351 when only 52000 (cystoscopy) was performed

Unbundling: Coding 52351 plus therapeutic code (52352-52356) same side same session

Medical necessity: Performing diagnostic ureteroscopy without appropriate indication or prior workup

Frequency: Repeat procedures without documented medical necessity

Summary

CPT 52351 represents an essential diagnostic tool in the urologist’s armamentarium for evaluating the upper urinary tract. This endoscopic procedure provides direct visualization of the ureter, renal pelvis, and calyces, allowing for comprehensive diagnostic assessment of various urologic conditions.

Key Points for Medical Coders:

• Diagnostic procedure only: Work RVU 5.75 reflects complexity of upper tract visualization
• Laterality mandatory: Always use RT, LT, or 50
• Bundling critical: Diagnostic ureteroscopy bundled into ALL therapeutic procedures
• 52332 exception: Stent placement separately reportable when no other therapeutic work
• Assistant surgeon NOT allowed: Indicator 1, no payment for assistant
• Global period 0 days: Post-op E/M visits separately billable
• Outpatient procedure: Most cases; inpatient rare unless comorbidities/complications
• Documentation critical: Must clearly state diagnostic intent and findings

For inpatient medical coders specializing in urology, understanding 52351 is essential for distinguishing diagnostic from therapeutic procedures. The code is commonly encountered in workup of hematuria, hydronephrosis, and suspected malignancy. When reviewing operative reports, the critical question is: “Was anything therapeutic done?” If yes, 52351 is NOT coded; use the appropriate therapeutic code instead.

The relatively moderate work RVU (5.75) reflects the skill required for flexible ureteroscopy and navigation of the intrarenal collecting system, while recognizing this is a diagnostic rather than therapeutic intervention. Proper code selection ensures accurate reimbursement, compliance with payer policies, and appropriate reflection of physician work.

Compliance reminders:

• Never code 52351 with therapeutic ureteroscopy codes same side same session
• Always document laterality
• Ensure medical necessity is clearly documented
• Query physicians when documentation is unclear about diagnostic vs. therapeutic nature

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References

¹AMA CPT Professional Edition
²AAPC Codify Cystourethroscopy Guidelines
³GenHealth Clinical Procedure Database
⁴CPT Coding Companion for Urology/Nephrology
⁵Boston Scientific Single-Use Ureteroscope Payment Guide Q1 2025
⁶CMS Physician Fee Schedule 2025
⁷FastRVU Urology Stone Procedures Guide
⁸CMS Assistant Surgeon Payment Policy Indicators
⁹AAPC Modifier Reference Guide
¹⁰CPT Professional Component Guidelines
¹¹AAPC NCCI Policy Manual
¹²CPT Assistant Bundling Guidelines
¹³CPT 2014 Guideline Revisions Ureteroscopy
¹⁴CMS HCC Risk Adjustment Model
¹⁵CMS MS-DRG Definitions Manual v43.0
¹⁶CMS OPPS Payment Methodology
¹⁷CPT Surgical Procedure Code Tree
¹⁸AAPC Coding Clinic Diagnostic Ureteroscopy
¹⁹Urology Coding Today Reference
²⁰Medicare Bilateral Surgery Payment Rules
²¹NCCI Procedure to Procedure Edits
²²AAPC Modifier 52 and 53 Guidelines
²³ICD-10-CM Cancer Surveillance Coding
²⁴CPT Multiple Procedure Guidelines
²⁵AAPC Ureteroscopy Bundling Rules
²⁶CMS Modifier 22 Documentation Requirements
²⁷AUA Coding Today Bilateral Procedures
²⁸NCCI Policy Manual Chapter VII Urinary System