51700 bladder irrigation documentation


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I have a question regarding the documentation of 51700 Bladder Irrigation, simple, lavage and/or instillation. When the physician does this and any other bedside procedures during the scope of either an office visit or hospital consult/follow-up, how are other urologist's documenting the procedure. Is there a separate procedure note for the irrigation or a detailed procedure paragraph within the actual visit note?

As auditing becomes more and more prevalent, we are coming across 2 carriers that will NOT process claims without FIRST auditing the visit notes due to their policy guidelines. We, as the billing company for a urologist are auditing notes, feel that the documentation is lacking; furthermore, these said carriers are also denying based on documentation.

Example #1 was taken from a DICTATED initial consultation note:

"Bladder irrigation was performed with 60ml of normal saline, 5 irrigations were performed through the bladder and 5 clots were evacuated until urine became completely cleared."

Example #2 is taken from a subsequent hospital visit and is not dictated because the hospital is still completely paper:

"Foley - I irrigated with 60cc NS foley until urine cleared."

Additionally if the physician is seeing the patient and all diagnosis billed are all urinary related, can the physician still be reimbursed for his follow-up visit even IF the reason for the irrigation (example: hematuria) is non-related to the other urinary symptoms/issues?