Wiki 51101 or 51102

[nabernhardt]

I think I am getting these 2 cpt codes confused. here is the procedure but am trying to determine whether to use 51101 or 51102?

The BK abdominal ultrasound probe was then used to identify the
bladder and make sure there was no bowel anterior to the bladder and there was not. The
bladder was readily identified. The site for the suprapubic placement was chosen and
anesthetized with 1% lidocaine. A small incision was made with an 11-blade scalpel.
The Rusch 16 French introducer was inserted into the bladder while watching with the
flexible cystoscope and a 16 Foley was placed through the sheath. The sheath was
removed. The balloon was inflated to 10 cc. The catheter was then placed to gravity
drainage. The cystoscope was removed.

 

[annettehai]

SP Cystostomy

51102 would be the correct choice since a catheter was placed. 51101 would simply be placement of the trocar, aspiration drainage of the bladder and then removal of the trocar.
I would also code 76942 for the ultrasound guidance of the trocar placement. If this was done in a facility setting, append modifier -26. There would need to be a separate paragraph for the radiologic findings and interpretation within in the note to meet the documentation guidelines for this code. If this was done in the office and the equipment in owned by the urologist, then bill it globally without the modifier.
Do not code/bill the cystourethroscopy since there is no documentation for the complete procedure and since it was done just to check the work, not to evaluate the urethra and bladder
A. Hai, RN, RNFA, CPC, CUC, ACS-UR