52352

Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included)

CPT code 52352 represents a comprehensive endoscopic procedure performed by a urologist to address calculi (stones) located within the ureter or renal pelvis. The formal descriptor is Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included). This minimally invasive intervention is an essential treatment modality for patients experiencing acute renal colic, obstructive uropathy, or persistent symptomatic stones that have not resolved with conservative medical expulsive therapy. During the procedure, the patient is typically placed in the dorsal lithotomy position under general, spinal, or deep sedation anesthesia. The physician begins by inserting a cystoscope through the urethral meatus, navigating it into the urinary bladder. This allows for direct visual inspection of the lower urinary tract and identification of the ureteral orifices. Once the target ureteral orifice is located, a guidewire is carefully advanced under fluoroscopic guidance through the orifice, up the ureter, and into the renal pelvis. Following guidewire placement, the physician introduces a ureteroscope, which may be either a semi-rigid or a flexible instrument depending on the anatomical location of the stone. The ureteroscope is advanced over the guidewire or alongside it, allowing for detailed direct visualization of the ureteral lumen and, if necessary, the inner structures of the kidney (pyeloscopy). Upon successfully locating the calculus, the urologist deploys specialized endoscopic instruments, such as a wire stone basket or mechanical grasping forceps, through the working channel of the ureteroscope. The stone is meticulously ensnared and extracted intact. In some clinical scenarios, rather than complete extraction, the stone is manipulated. For instance, it may be pushed proximally into the renal pelvis (a maneuver known as pushback) to relieve an acute obstruction or to optimally position the calculus for subsequent extracorporeal shock wave lithotripsy (ESWL). It is crucial for accurate medical coding and billing to note that CPT code 52352 applies strictly to the removal or manipulation of stones that remain whole or are removed without the need for intra-corporeal fragmentation. If the stone is too large or impacted and requires the use of laser, pneumatic, or electrohydraulic lithotripsy to be broken down before the fragments can be extracted, the appropriate code to report would be CPT 52353 instead. Furthermore, the descriptor explicitly states that standard ureteral catheterization is bundled into this code and should not be reported separately. However, if a temporary indwelling double-J ureteral stent is placed at the conclusion of the procedure to ensure proper urinary drainage and to prevent stricture or swelling, CPT code 52332 may often be reported in conjunction with 52352, subject to specific National Correct Coding Initiative (NCCI) edits and appropriate modifier usage (such as modifier 51 for multiple procedures). Comprehensive documentation of the exact procedural steps, instruments used, and the ultimate fate of the calculus is imperative to substantiate the selection of CPT 52352.

Clinical Indications

  • Ureteral calculus (stones)
  • Renal calculus (stones)
  • Obstruction of the ureter due to a calculus
  • Unsuccessful conservative management of ureteral stones or failed medical expulsive therapy
  • Acute renal colic with identifiable stone on imaging

Procedure Steps

  1. The patient is positioned in the dorsal lithotomy position and administered appropriate anesthesia.
  2. The external genitalia and perineum are prepped and draped in a sterile fashion.
  3. A cystourethroscope is introduced through the urethra into the bladder to inspect the lower urinary tract and identify the ureteral orifices.
  4. A guidewire is passed through the cystoscope, into the affected ureteral orifice, and advanced under fluoroscopic guidance to the renal pelvis.
  5. A rigid or flexible ureteroscope is advanced over the guidewire to visually inspect the ureter and/or renal pelvis.
  6. The offending calculus is visually identified within the ureter or renal pelvis.
  7. An endoscopic retrieval tool, such as a stone basket or grasping forceps, is passed through the working channel of the ureteroscope.
  8. The calculus is engaged, captured, and either gently extracted intact from the urinary tract or manipulated into a more optimal position (e.g., pushed back into the renal pelvis).
  9. The ureter is re-inspected to ensure no additional stones remain and to verify that no mucosal injury has occurred.
  10. Instruments are removed, and an indwelling ureteral stent may be placed if clinically indicated for postoperative drainage.

Coding Guidelines

  • CPT code 52352 is reported when a stone is removed intact or manipulated without the use of lithotripsy. If lithotripsy is required to fragment the stone, report CPT 52353 instead.
  • Ureteral catheterization is inherently included in 52352 and should not be reported separately with codes such as 52005.
  • If a self-retaining indwelling double-J ureteral stent is inserted at the end of the procedure, CPT 52332 may be reported separately, often requiring modifier 51, subject to payer-specific NCCI edits.
  • For bilateral procedures, append modifier 50 to 52352.
  • Do not report 52352 for the same stone if 52353 or 52356 is performed during the same operative session on the same side.
  • Routine fluoroscopic guidance is generally considered inclusive; check specific payer rules before reporting 74420 or 76000.

Associated ICD-10 Codes