Urolift Procedure for Medical Coder

What is Urolift Procedure ?

Urolift procedures are the placement of an implant in the prostate to hold the enlarged prostate tissue away from the urethra and to keep passage open. 

What are the medical reason for the Urolift procedure ?

Urolift procedure is performed to treat BPH (Benign Prostate Hyperplasia) , which means enlarged prostate.

Urolift vs TURP 

1.Urolift is the minimal invasive procedure whereas TURP is invasive surgery . 

2.In Urolift Sexual function can be preserved but in TURP it may create temporary or permanent erectile dysfunction. Also,TURP usually causes retrograde ejaculation.

3.Urolift is selected for small or moderate prostate hyperplasia but for large prostate hyperplasia, physicians go with TURP.

[ Retrograde Ejaculation is a condition where semen flows backward into the bladder instead of exiting the body during orgasm. ]

How much Urolift Procedure Cost

(Price for Urolift Procedure as per CCI)

For Non-Facility

$1,161.56 for 52441

$792.17 for 52442

For Facility

$201.84

$48.84

Note: The amount may vary because depends upon insurance and payor guidelines.

Prosate Gland after Placing Implant [Image for Illustration]

CPT Code for Urolift Procedure

As per medical coding the CPT for Urolift procedure are :

52441 : Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant

+52442 :Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure)

Coding Tips for Urolift Procedure

Urolift are the implants that reshape and expand the prostatic passage so that the obstruction associated with a diagnosis of benign prostatic hyperplasia (BPH) is reduced. 

The number of implants is determined by the size and anatomy of the prostate during the initial cystourethroscopy (52441) by physician choice. Add-on code 52442 may be reported multiple times, as appropriate, for each additional implant after the initial implant is placed.

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Operative Report for Urolfit Procedure

[This report is created by AI for maintain privacy of patient , good for learning ]

Date of Surgery: [DD/MM/YYYY]

Estimated Blood Loss: Minimal

Specimens: None

Surgeon: [Medycoding Expert, MD]

Assistant: None

Preoperative Diagnosis: Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms (LUTS)

Postoperative Diagnosis: Same

Procedure Performed: Cystourethroscopy and UroLift implantation (Prostatic Urethral Lift)

Anesthesia: Monitored Anesthesia Care (MAC) with local anesthesia

Indications for Surgery

The patient is a 60-year-old male (named medycoder) with a history of lower urinary tract symptoms secondary to benign prostatic hyperplasia. Symptoms included decreased urinary stream, hesitancy, frequency, and nocturia. After discussing medical management options and failure of conservative treatment, the decision was made to proceed with a UroLift procedure.

Description of Procedure

After obtaining informed consent, the patient was brought to the operating room and placed in the lithotomy position. Appropriate IV sedation was administered, and the genital area was prepped and draped in the usual sterile fashion.

A 22 Fr cystoscope sheath was introduced into the urethra under direct vision using a 30-degree lens. The urethra and bladder were inspected. The prostate was noted to have lateral lobe hypertrophy with no significant median lobe. The bladder was otherwise normal, with no evidence of tumor or stones.

The UroLift delivery device was then introduced through the cystoscope. Under direct visualization, the first implant was deployed approximately 1.5 cm distal to the bladder neck on the left lateral lobe. The capsular tab was seen tenting the lateral lobe, creating an open anterior channel.

A second implant was placed in a symmetric position on the right lateral lobe at the same level. Two additional implants were placed distally on each side to ensure adequate urethral lumen patency, making a total of four implants deployed.

Cystoscopy confirmed a widely patent anterior channel through the prostatic urethra. There was no evidence of bleeding or mucosal injury. The bladder was drained and inspected once again before withdrawing the scope.

The patient tolerated the procedure well. No catheter was left in place.

Get Explanation of this Op note in above video

CPT code for Urolift Procedure in Above :

52441 ( Primary procedure for 1st Implant )

52442* ( For other additional 3 Implants placed )

Learn More about Urolift Procedure

https://my.clevelandclinic.org/health/procedures/prostatic-urethral-lift