Clinical UM Guideline
Subject: Outpatient Cystourethroscopy
Guideline #: CG-SURG-51 Publish Date: 07/06/2022
Status: Reviewed Last Review Date: 05/12/2022
Description

This document addresses cystourethroscopy in the outpatient setting.

Clinical Indications

Medically Necessary:

Outpatient cystourethroscopy is considered medically necessary for any of the following indications:

  1. Gross hematuria without evidence of glomerular disease or infection; or
  2. Gross hematuria with blood clots; or
  3. Microscopic hematuria without evidence of glomerular disease, infection, or known cause of hematuria and there is an increased risk for malignancy; or
  4. Management of kidney stones unlikely to pass spontaneously; or
  5. Suspected surgical urinary tract injury or foreign body (for example, injury to the ureter, incision into the bladder, intravesical placement or erosion of mesh or suture); or
  6. Urinary urgency, urinary frequency, or urgency incontinence when there is no urinary tract infection (this also includes stress urinary incontinence); or
  7. Suspected malignant involvement of the urinary tract (including diagnosis and staging of bladder cancer, as well as diagnosis and staging of cervical, endometrial, ovarian, vulvar, vaginal, and other gynecologic malignancies); or
  8. Urine leakage from the vagina (for example, from a genitourinary fistula); or
  9. Lower genital tract trauma with suspicion of urinary tract involvement, including urethral stricture; or
  10. Urine dribbling post voiding (for example, from a urethral diverticulum); or
  11. Injection of therapeutic agents for urinary incontinence; or
  12. Verification of suprapubic catheter placement; or
  13. Removal of indwelling ureteral stents not amenable to office-based procedure; or
  14. Recurrent urinary tract infection (defined as 3 or more urinary tract infections in 12 months) when any of the following risk factors are present:
    1. Prior urinary tract surgery or trauma; or
    2. Gross hematuria after resolution of infection; or
    3. Previous bladder or renal calculi; or
    4. Obstructive symptoms (such as straining, weak stream, intermittency, hesitancy), low uroflowmetry or high post void residual; or
    5. Urea-splitting bacteria on culture (for example, Proteus, Yersinia); or
    6. Bacterial persistence after sensitivity-based therapy; or
    7. Prior abdominopelvic malignancy; or
    8. Diabetes or otherwise immunocompromised; or
    9. Pneumaturia, fecaluria, anaerobic bacteria or a history of diverticulitis; or
    10. Repeated pyelonephritis (fevers, chills, vomiting, costovertebral tenderness); or
    11. Asymptomatic microhematuria after resolution of infection.

Not Medically Necessary:

Outpatient cystourethroscopy is considered not medically necessary for any other indication not listed above as medically necessary.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met for outpatient procedures:

CPT

 

52000

Cystourethroscopy (separate procedure)

52001

Cystourethroscopy with irrigation and evacuation of multiple obstructing clots

52005

Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service;

52007

Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with brush biopsy of ureter and/or renal pelvis

52010

Cystourethroscopy, with ejaculatory duct catheterization, with or without irrigation, instillation, or duct radiography, exclusive of radiologic service

52204

Cystourethroscopy, with biopsy(s)

52214

Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands

52224

Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy

52234

Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)

52235

Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm)

52240

Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s)

52250

Cystourethroscopy with insertion of radioactive substance, with or without biopsy or fulguration

52260

Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia

52265

Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia

52270

Cystourethroscopy, with internal urethrotomy; female

52275

Cystourethroscopy, with internal urethrotomy; male

 

 

ICD-10 Diagnosis

 

 

All diagnoses, including, but not limited to:

C51.0-C57.9

Malignant neoplasm of vulva, vagina, cervix uteri, corpus uteri, uterus, ovary, other and unspecified female genital organs

C64.1-C68.9

Malignant neoplasms of urinary tract

C79.00-C79.19

Secondary malignant neoplasm of kidney and renal pelvis, bladder and other and unspecified urinary organs

D09.0-D09.19

Carcinoma in situ of bladder, other and unspecified urinary organs

D17.71-D17.72

Benign lipomatous neoplasm of kidney, other genitourinary organs

D30.00-D30.9

Benign neoplasm of urinary organs

D41.00-D41.9

Neoplasm of uncertain behavior of urinary organs

D49.4-D49.5

Neoplasms of unspecified behavior of bladder, other genitourinary organs

N02.0-N02.A

Recurrent and persistent hematuria

N13.1-N13.9

Obstructive and reflux uropathy

N20.0-N21.9

Calculus of kidney and ureter, lower urinary tract

N22

Calculus of urinary tract in diseases classified elsewhere

N30.00-N30.91

Cystitis

N32.0

Bladder-neck obstruction

N34.0-N34.3

Urethritis and urethral syndrome

N35.010-N35.92

Urethral stricture

N39.0

Urinary tract infection, site not specified

R80.0-R82.99

Abnormal findings on examination of urine, without diagnosis

Z85.50-Z85.59

Personal history of malignant neoplasm of urinary tract

Z87.440-Z87.448

Personal history of diseases of the urinary system

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

Discussion/General Information

A cystoscopy is a surgical procedure in which a tube with a small camera on the end (endoscope) is inserted into the bladder to examine the lumen of the bladder, urethra, and the prostate. A related procedure, the urethroscopy, is done to examine the urethral lumen to look for urethral diseases or abnormalities. For the cystoscopy, the endoscope is inserted into the urethra which allows visualization of both the bladder and the urethra, thus the term cystourethroscopy. In addition to the camera, small instruments can also be passed through the endoscope that can be used to treat urinary problems. A diagnostic cystourethroscopy can be done as part of an evaluation of abnormal symptoms or laboratory findings. Cystourethroscopy can be performed with local anesthesia while the member is awake, but it can also be performed during or after pelvic surgery with regional or general anesthesia.

Hematuria can occur with or without other urinary tract symptoms. Without symptoms, hematuria may still be indicative of urinary or bladder problems. A 2012 study by Cha reported on 1182 participants who presented with asymptomatic hematuria. A total of 245 participants were found to have bladder cancer; 138 had low-grade tumors while 97 participants had high-grade tumors. While there are limitations to this study, including a possible increased probability of bladder cancer in the cohort based on local referral patterns, the results indicate that hematuria should not be ignored.

Goldberg and colleagues (2008) reviewed the charts of 1584 participants who had lower urinary tract symptoms and subsequent cystourethroscopy in an attempt to ascertain whether microscopic hematuria was a reliable predictor of cancer risk. Microscopic hematuria was found in 14.8% of the participants, with 1.7% then found to have biopsy-confirmed bladder cancer. Among the participants without hematuria, 0.45% were found to have bladder cancer and 60% of the participants presented with a normal initial dipstick urinalysis. While this study has some limitations including its retrospective design, the findings suggest that cystourethroscopy can be used for the evaluation of lower urinary tract symptoms including hematuria.

In a 2015 study of 109 participants with hematuria, Ahmed and colleagues compared transabdominal ultrasound to cystourethroscopy. All participants had both ultrasound and cystourethroscopy. The authors concluded that while ultrasound can be used as a first-line imaging tool for evaluation of hematuria in settings where cystourethroscopy is not available, it cannot replace cystourethroscopy as the gold standard for evaluation of hematuria.

Whether or not a stone passes spontaneously, stone passage can depend on the size and/or location of the stone. According to a 2016 American Urological Association guideline for the surgical management of stones, ureteroscopy can be used for mid or distal ureteral stones.

In 2019 the American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction published their guideline regarding recurrent uncomplicated urinary tract infection in women. This guideline refers to “an otherwise healthy adult female with an uncomplicated recurrent urinary tract infection." The authors define a recurrent urinary tract infection as “two separate culture-proven episodes of acute bacterial cystitis and associated symptoms within six months or three episodes within one year.” Upon evaluation, according to expert opinion, for a healthy adult individual with an uncomplicated recurrent urinary tract infection, cystoscopy and upper tract imaging should not be routinely done.

While cystourethroscopy is considered to be the gold standard procedure for many indications and is a low-risk surgical procedure, like all surgical procedures it is not without risk. A 2014 study by Rambachan and colleagues reported on surgical outcomes and the rate of hospital readmissions following urological surgery. In looking at 7795 participants, outpatient urological surgery had a 3.7% readmission rate within 30 days. Cystourethroscopy and resection of bladder tumor was the most common procedure that had been performed. However, it is important to keep in mind that certain gynecologic surgical procedures themselves are considered to be high-risk for complications and the addition of cystourethroscopy may help to avoid additional surgery.

Definitions

Cystourethroscopy: A 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: Blood in the urine which is visible to the naked eye.

Hematuria: Blood in the urine.

Microscopic hematuria: Blood in the urine which is only visible by a microscope.

References

Peer Reviewed Publications:

  1. Ahmed FO, Hamdan HZ, Abdelgalil HB, Sharfi AA. A comparison between transabdominal ultrasonographic and cystourethroscopy findings in adult Sudanese patients presenting with haematuria. Int Urol Nephrol. 2015; 47(2):223-228.
  2. Cha EK, Tirsar LA, Schwentner C, et al. Accurate risk assessment of patients with asymptomatic hematuria for the presence of bladder cancer. World J Urol. 2012; 30(6):847-852.
  3. Gilmour DT, Das S, Flowerdew G. Rates of urinary tract injury from gynecologic surgery and the role of intraoperative cystoscopy. Obstet Gynecol. 2006; 107(6):1366-1372.
  4. Gleason JL. Cystoscopy and other urogynecologic procedures. Obstet Gynecol Clin North Am. 2013; 40(4):773-785.
  5. Goldberg RP, Sherman W, Sand PK. Cystoscopy for lower urinary tract symptoms in urogynecologic practice: the likelihood of finding bladder cancer. Int Urogynecol J Pelvic Floor Dysfunct. 2008; 19(7):991-1004.
  6. Rambachan A, Matulewicz RS, Pilecki M, et al. Predictors of readmission following outpatient urological surgery. J Urol. 2014; 192(1):183-188.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Urological Association. Surgical management of stones: American Urological Association/Endourological Society Guideline. 2016. Available at: https://www.auanet.org/guidelines. Accessed on April 11, 2022.
  2. American Urological Association (AUA)/Canadian Urological Association (CUA)/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction (SUFU). Recurrent uncomplicated urinary tract infections in women: AUA/CUA/SUFU guideline. 2019. Available at: https://www.auanet.org/guidelines/recurrent-uti. Accessed on April 11, 2022.
  3. Barocas DA, Boorjian SA, Alvarez RD et al. Microhematuria: AUA/SUFU guideline. J Urol. 2020; 204(4):778-786. Available at: https://www.auanet.org/guidelines/microhematuria. Accessed on April 11, 2022.
  4. Grossfeld GD, Wolf JS Jr, Litwan MS, et al. Asymptomatic microscopic hematuria in adults: summary of the AUA best practice policy recommendations. Am Fam Physician. 2001; 63(6):1145-1154.
  5. Rodgers M, Nixon J, Hempel S, et al. Diagnostic tests and algorithms used in the investigation of haematuria: systematic reviews and economic evaluation. Health Technol Assess. 2006; 10(18):iii-iv, xi-259.
Websites for Additional Information
  1. National Institute of Diabetes and Digestive and Kidney Diseases. Available at: https://www.niddk.nih.gov/health-information/diagnostic-tests/cystoscopy-ureteroscopy. Accessed on April 11, 2022.
Index

Cystoscopy
Cystourethroscopy
Urethroscopy

History

Status

Date

Action

Reviewed

05/12/2022

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion/General Information and References sections.

Reviewed

05/13/2021

MPTAC review. Updated References section. Reformatted Coding section.

 

10/01/2020

Updated Coding section with 10/01/2020 ICD-10-CM changes; added N02.A.

Reviewed

05/14/2020

MPTAC review.

Reviewed

06/06/2019

MPTAC review. Updated Discussion/General Information and References sections.

Reviewed

07/26/2018

MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 10/01/2018 ICD-10-CM changes to diagnosis range N35.010-N35.92.

Reviewed

08/03/2017

MPTAC review. Updated Definitions section.

Reviewed

08/04/2016

MPTAC review. Updated formatting in Clinical Indications section. Updated Discussion/General Information and Reference sections. Removed ICD-9 codes from Coding section.

New

08/06/2015

MPTAC review. Initial document development.

 

 

 

 


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