52318

Cystourethroscopy with Lithotripsy of Large or Complicated Bladder Stone (> 2.5 cm)

Cystourethroscopy with lithotripsy for a large or complicated bladder stone (CPT 52318) is a surgical urological procedure performed to fragment and remove significant stone burdens within the urinary bladder. This procedure is specifically designated for stones that are greater than 2.5 centimeters in their largest dimension or those characterized as clinically complicated due to factors such as stone density, location, or the presence of multiple stones that create a significant total burden. The procedure begins with the patient in the lithotomy position, under appropriate anesthesia. The urologist inserts a cystourethroscope through the urethra to visualize the bladder interior, identifying the stone's size, number, and composition. Once the calculus is localized, a lithotripsy device—which may use laser (such as Holmium:YAG), ultrasonic, pneumatic, or electrohydraulic energy—is introduced through the working channel of the scope. The energy is applied directly to the stone until it is broken into fragments small enough to be aspirated or irrigated out of the bladder. In complicated cases, a mechanical lithotrite (a crushing instrument) may be used to physically break the stone. After fragmentation is complete, an Ellik evacuator or a similar irrigation-suction device is used to remove all debris. The surgeon then performs a final inspection of the bladder wall to ensure no mucosal injury occurred and that the bladder is clear of significant fragments. A Foley catheter is often placed at the conclusion of the procedure to allow for continuous drainage and to monitor for postoperative hematuria. This code excludes simple or small stones (less than 2.5 cm), which are instead reported under CPT 52317. Detailed operative documentation of the stone size or the specific complexities encountered is essential for justifying the use of 52318 over the lower-intensity code.

Clinical Indications

  • Vesical calculi (bladder stones) greater than 2.5 cm in diameter.
  • Chronic urinary retention caused by large bladder stones.
  • Recurrent urinary tract infections (UTIs) associated with significant bladder stone burden.
  • Gross or microscopic hematuria secondary to bladder stone irritation.
  • Severe lower urinary tract symptoms (LUTS) such as dysuria, frequency, and urgency.
  • Stones complicated by bladder diverticula or neurogenic bladder dysfunction.
  • Failure of conservative management for large symptomatic calculi.

Procedure Steps

  1. Place the patient in the dorsal lithotomy position and administer general or regional anesthesia.
  2. Perform a surgical prep and drape of the perineal area.
  3. Introduce a rigid or flexible cystourethroscope into the urethra and advance it into the bladder.
  4. Inspect the bladder mucosa and identify the calculus, confirming its size and position.
  5. Pass a lithotripsy probe (laser, ultrasonic, or pneumatic) through the cystoscope channel.
  6. Fragment the stone by applying energy directly to the stone surface until pieces are small enough for evacuation.
  7. Use a mechanical lithotrite if necessary for extremely hard or large stones to facilitate initial breakage.
  8. Irrigate the bladder and use an Ellik evacuator to remove all stone fragments and dust.
  9. Perform a final cystoscopic survey to confirm complete stone clearance and assess for mucosal trauma.
  10. Place a Foley catheter if indicated for post-operative drainage and monitoring.
  11. Remove the cystoscope and document the stone size and technique used in the operative report.

Coding Guidelines

  • Report 52318 for lithotripsy of a bladder stone greater than 2.5 cm or those considered complicated.
  • Do not report 52318 in conjunction with 52317 (lithotripsy for simple/small stone) for the same session.
  • Cystourethroscopy (52000) is considered an inherent part of the procedure and should not be billed separately.
  • If the procedure is performed as part of a more extensive procedure like a prostatectomy, check NCCI edits for bundling.
  • Documentation must clearly state the stone size (exceeding 2.5 cm) or the specific clinical factors that made the stone 'complicated' to support the higher level of service.
  • Use modifier 52 if the procedure is significantly reduced in scope or modifier 53 if discontinued due to patient safety.

Associated ICD-10 Codes