Urology Coding Alert

Question: If a patient has transurethral bulking (51715), goes home with a catheter, returns three days later, and has a post voiding trial, is the post voiding trial billable?

South Carolina Subscriber

Answer: Since 51715 (Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck), which you reported for the transurethral bulking procedure, has a zero-day global, all post-operative care is billable. Therefore, for the post voiding trial three days later you can report 51700 (Bladder irrigation, simple, lavage and/or instillation).

Additionally: If your urologist performed a significant and separately identifiable E/M service for a separate problem, unrelated to the bulking procedure, you may be able to bill an appropriate E/M code as well. Remember to add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M service when billed with the surgical procedure 51700.