Urology Coding Alert

Question: My MD is asking if you can bill 51728 if the patient tries to void but is unable to. He does this procedure during urodynamic testing. Basically the intent and physician effort is there; however, due to stage-fright or something else, the patient cannot void. Is that billable?

Oregon Subscriber

Answer: Unfortunately, if the patient is unable to void, then you cannot bill any voiding measurements because none can really be made. That means reporting 51728 (Complex cystometrogram [ie, calibrated electronic equipment]; with voiding pressure studies [ie, bladder voiding pressure], any technique), 51729 (…with voiding pressure studies [ie, bladder voiding pressure] and urethral pressure profile studies [ie, urethral closure pressure profile]; any technique), 51736 (Simple uroflowmetry [UFR] [eg, stop-watch flow rate, mechanical uroflowmeter]), and 51741 (Complex uroflowmetry [eg, calibrated electronic equipment]) under these circumstances is not appropriate. 

Remember: Since you cannot bill any voiding studies when the patient does not void, you also cannot bill for rectal pressure using +51797 (Voiding pressure studies, intra-abdominal [ie, rectal, gastric, intraperitoneal] [List separately in addition to code for primary procedure]). This is an add-on code which is dependent on the reporting of 51728 or 51729 and can never be reported on its own. 

Other urodynamic studies unrelated to urinary voiding may be billed and paid during this type of clinical encounter wherein the patient is unable to void.