The Journey to Office Cystoscopy Privileging

Christy B. Krieg, MSN, FNP, CUNP


Urol Nurs. 2020;40(2):99-103. 

In This Article

After the Panic

Now, 2.5 years into performing independent cystoscopy, here are some notable practical details. First, I have had no issues with reimbursement or challenges from payers when billing under my own National Provider Number (NPI). Further, I am not aware of any lesions I have missed, although there is still the potential for future discovery of an oversight – my greatest fear. Third, I have made referrals for biopsy to at least 10 physician colleagues; none have provided feedback suggesting my notes are lacking in clarity or my judgment inappropriate. I have, on occasion during office cystoscopy, requested physician assistance or input; on those occasions, I request the billing be attributed to the physician.

Regarding productivity increases, my Relative Value Units (RVUs) for 2018 billed under diagnostic flexible cystoscopy CPT code 52000 were 341. Due to other changes in my practice from 2016 to 2018, I cannot associate other increases in my total RVU to cystoscopy alone, though I often perform evaluation and management services along with the cystoscopy.

Has independently performing cystoscopy impacted wait times for my patients? I cannot be sure, but efficiency is certainly improved when initial consultation and cystoscopy are performed in a single visit. Further, it has absolutely resulted in better continuity of care and freed surgeons from this billable task for patients who are primarily mine.

While I have developed a greater comfort with cystoscopy overall, I prefer patients with diagnosed bladder cancer, especially carcinoma in situ (CIS), have surveillance cystoscopy with their surgeon of record. I am comfortable telling patients that urologists in my practice are inherently more experienced than I at cystoscopy. I never overstate my qualifications, typically saying, "I am a nurse practitioner, not a doctor, with 20 years of experience in urology. I work with a team of physicians, and if I need help or a patient needs surgery, I will consult or refer you to a trusted physician colleague." I believe patients understand that distinction clearly when I consent them for the procedure, describing the typically minor risks of infection, bleeding, and discomfort.

To my recollection, only two patients have refused cystoscopy with me, preferring a physician perform the diagnostic cystoscopy. This is akin to patients refusing to see me for care early in my practice, stating, "No, I'm here to see a doctor." That happens rarely now, and parallel to patient acceptance of APPs managing their care, patients seem confident in my qualification to perform cystoscopy.

I have had one major complication: a male patient with reported gross hematuria, normal urine analysis, and without risk factors developed urosepsis after cystoscopy and had a short stay in ICU. Once discharged, he contacted our department chair, who explained to him that not providing prophylactic antibiotic meets standard of care, though with a regrettable outcome in his case. I had followed the American Urological Association (AUA) guideline (Wolf et al., 2012). Findings on his cystoscopy were benign prostatic hyperplasia (BPH) and the presence of inflammatory polyps in the prostatic urethra. Based on this event, I now recommend quinolone prophylaxis for men who are found on cystoscopy to have obstruction and inflammation.

A second change to my practice over these three years relates to high rates of benign biopsies. While papillary lesions are undeniably abnormal, my rate of referral for biopsy of small, non-papillary lesions has been high. The pathologist may report (somewhat embarrassingly) "minute fragment of benign urothelium." While the majority of these small lesions have inflammatory features and are not cancerous, one was a tiny CIS with normal cytology. My assessment, therefore, is that I may be over-biopsying. To correct this, I am working with very sympathetic collaborating physicians (one said of his own early practice, "I biopsied everything when I was getting started!").

To reduce morbidity of anesthetic biopsy of benign lesions, we have preliminarily made the following plan just recently for these tiny, non-papillary lesions. Assuming cytology is negative, I now offer anesthetic biopsy or follow-up flexible cystoscopy with a staff physician in three months. Though not part of the AUA guideline, our department has a culture of great confidence in our cytopathologists, and we use cytology liberally in my facility.

I am currently the only NP performing cystoscopy in our large practice group, but we have had many excellent NP hires in recent years. For now, this has changed my referral patterns. NPs in my department are referring their patients to me for cystoscopy rather than to their collaborating physicians. While I chalk that up to wait times at least in part, their confidence in me is heartening. Often the referring NP is seeing patients in the same clinic, and we can provide continuity and shared decision-making for the patient by dual staffing cystoscopy. We review the case together, I perform cystoscopy with an NP colleague present, and we decide together on a plan of care.