Revenue Cycle Insider

Question: I have a report for a patient who presented to their urologist complaining of urinary incontinence. The urologist performed a cystometrogram with bladder voiding pressure and urethral pressure measurements, which revealed stress incontinence. The physician recommended a sling procedure to treat the patient’s condition, which was scheduled for four weeks later.

How do I report this encounter?

Alabama Subscriber

Answer: Assign 51729 (Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique) to report the cystometrogram with pressure measurement studies. Cystometrogram is a type of urodynamics testing that measures how well the patient’s bladder can hold and eliminate urine. The test also evaluates the pressure inside the bladder while it is filling.

In the CPT^® Index, search for Urodynamic Tests and locate Cystometrogram, which provides you with a range of codes to verify. Turn to Urinary System codes in the Surgery chapter to verify the correct code. Under the Urodynamics section, you’ll find that 51729 is designated for a complex cystometrogram with voiding pressure studies and urethral pressure studies.

Next, you’ll open the ICD-10-CM code book to locate the code for stress incontinence. In the Alphabetic Index, search for Incontinence > stress (female) (male), which provides you with a code to verify in the Tabular List. In the Tabular List, you’ll find N39.3 (Stress incontinence (female) (male)) for the patient’s diagnosis.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC