Urology Coding Alert

Question: Our urologist saw an established patient who had gotten a catheter inserted in the emergency department. The catheter was put in wrong, so the patient was in retention. Our physician removed the catheter and replaced it using a catheter guide after a bladder scan showed 1,000 cc. Initially he also had to do a urethral dilation. Would you help me determine which procedures and services I can code for?


Indiana Subscriber


Answer: First, you should report the office visit. Assuming your urologist performed a significant H&P, report 99213 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity).

Append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) because the physician performed other services during the same visit.
 
Next: Report 51703 (Insertion of temporary indwelling bladder catheter; complicated [e.g., altered anatomy, fractured catheter/balloon]) for the difficult catheterization after the urethral dilation. The urologist's use of a catheter guide to insert the Foley catheter warrants 51703.

Third: For the urethral dilation, you should use 53600 (Dilation of urethral stricture by passage of sound or urethral dilator, male; initial). Append modifier 51 (Multiple procedures) because the urologist performed more than one procedure during the same session.

Don't miss: Remember to report 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging) for the sonographic determination of post-voiding residual. Because this is a radiological procedure, you don't need any modifiers.