ED Coding and Reimbursement Alert

Question: A patient reports to the ED complaining of urinary symptoms; he says that he "hasn't peed since yesterday," and he reports a 7 on a 10-point pain scale. Notes indicate that following several attempts by the nurse, the physician easily inserts a "coude tip catheter" to drain the urine. Is the catheter insertion part of the E/M?

Oregon Subscriber

Answer: Provided the physician inserted the catheter himself, and the patient meets the insurer's requirements for catheter insertion, you can separately report it.

On the claim, report the following:

• 51702 (Insertion of temporary indwelling bladder catheter; simple [e.g., Foley]) for the insertion

• the appropriate level ED E/M code based on the notes (99281-99285, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: ...)

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M to show that it was separate from the insertion

• 788.20 (Retention of urine, unspecified) appended to 51702 and the E/M to represent the patient's retention

Medical necessity check: As your patient was not able to urinate for an extended time, the payer should accept the catheter code with 788.20 as a diagnosis -- but be sure to check first. According to Medline Plus, urinary catheters could be necessary when the patient:

• suffers urinary incontinence (a urine leakage or the inability to control when you urinate, 788.3x, Urinary incontinence ...)

• suffers from other medical conditions such as multiple sclerosis (340, Multiple sclerosis), spinal cord injury (952.xx, Spinal cord injury without evidence of spinal bone injury ...; 953.x, Injury to nerve roots and spinal plexus ...), or dementia (290.xx, Dementias ...; 294.1x, Dementia in conditions classified elsewhere ..).

• has had a procedure that necessitated a catheter necessary, such as prostate or gynecological surgery.

Note: For more catheter information, check out www.nlm.nih.gov/medlineplus/ency/article/003981.htm.