ED Coding and Reimbursement Alert

Question: A patient with acute urinary retention (AUR) resulting in lower urinary tract obstruction received an emergency urethral catheterization in the ED to decompress the bladder. The Foley catheter was left in place and a subsequent ultrasound (US) scan of the urinary bladder revealed that the underlying cause of the AUR was benign prostatic hyperplasia. How should we code this situation?

North Carolina Subscriber

Answer: The emergency services performed to treat this patient’s urinary tract obstruction are relatively straightforward. Using the CPT^® index, Catheter/Catheterization ⇒ Bladder ⇒ Insertion narrows your choice down to the following codes:

• 51701 (Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine))
• 51702 (Insertion of temporary indwelling bladder catheter; simple (eg, Foley))
• 51703 (Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon))

Since you have documentation supporting that the catheter remained in place, you can immediately rule out code 51701. Your choice between codes 51702 and 51703 depends on whether the physician encountered any underlying difficulty placing the catheter. The code description for 51703 outlines a few scenarios that might result in the provider opting for increased reimbursement due to the degree of difficulty of the procedure.

If the provider places the catheter without any issues, you’re likely to bill for a simple insertion. Only the physician can make the determination of difficulty and should subsequently document the degree of difficulty encountered to support the complicated catheter placement, when applicable.