Urology Coding Alert

Question: When my urologist does a bladder scan in the office, which code should I use? I know there is 51798 and 76775. From what I can tell, 51798 is the code to use when the urologist doesn't take an image, and 76775 when he does take images. Is that correct?

Alabama Subscriber Answer: Whether or not the urologist obtains images is inconsequential. The use of the proper CPT code depends on the reason for the sonogram. If the urologist does the bladder sonogram primarily to determine the post-void residual urine (PVR), use 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging) no matter what equipment the urologist uses, and whether or not he derives an image from the equipment.

If the urologist uses the sonogram primarily to view the anatomy or architecture of the bladder, and the PVR is only part of - but not the main reason for - the study, bill 76775 (Ultrasound, retroperitoneal [e.g., renal, aorta, nodes], B-scan and/or real time with image documentation; limited).

Beware: The second instance is the only circumstance in which you should bill 76775. Most urologists do a bladder sonogram primarily for PVR determination and should be billing with 51798.