Wiki 51702 or 51703 in ER?

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tori.a

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Hi! How would you code the following? The provider wants to bill 51703 but this note says he did not have any difficulty. Would this be enough to qualify as an E/M? He was discharged from the hospital on 11/26 then returned to the ER next day for inability to void. Thanks!

DATE OF CONSULTATION: 11/27/2021
REASON FOR CONSULTATION:
Urinary retention.

HISTORY OF PRESENT ILLNESS:
The 73-year-old gentleman with a history of BPH, who underwent a cystoscopy and left ureteroscopy and laser lithotripsy earlier in the week, had his ureteral stent and Foley catheter removed 24 hours ago. He has had progressive difficulty voiding and he cannot currently void and attempts by the ER nurse to place a catheter was unsuccessful, and I was called. The patient was prepped and draped in usual fashion, and a 16-French coude catheter was easily advanced without difficulty. Balloon was inflated with 10 mL of sterile water. He had over 500 mL Pyridium stained urine drained. The patient has been advised to follow up with his urologist in New York, but if he runs into any issues or difficulties while he is here, he can contact us. 20211127 DL
 
Since the physician used a coude catheter, I would bill 51703. There is not enough documentation in this note to bill an E/M service.
 
Thank you so much, I didn't realize a coude catheter made it complicated so that really helps. Now I know that's something to look for. Thanks again!!
 
I was told that to code a complicated catheter insertion, there needs to be documentation of what made it difficult, like a urethral stricture, and that saying a Coude was used isn't enough. This makes sense when reading the CPT description.

From the Coders' Desk Reference for Procedures:
The patient is catheterized with a non-indwelling bladder catheter (e.g., for residual urine) in 51701; simple catheterization with a temporary indwelling bladder catheter (Foley) is performed in 51702. The area is properly cleaned and sterilized. A water-soluble lubricant may be injected into the urethra before catheterization begins. The distal part of the catheter is coated with lubricant. In males, the penis is held perpendicular to the body and pulled up gently and the catheter is steadily inserted about 8 inches until urine is noted. In females, the catheter is gently inserted until urine is noted. With an indwelling catheter, insertion continues into the bladder until the retention balloon can be inflated. The catheter is gently pulled until the retention balloon is snuggled against the neck of the bladder. The catheter is secured to the abdomen or thigh and the drainage bag is secured below bladder level. Report 51703 if a change in anatomy, such as enlarging of the prostate or a fractured catheter or balloon, complicate the catheterization process.
 
Where was the procedure performed, in the physician's office or a facility? The OP was about the procedure being done in the ER. If it was performed in a facility, then I would bet the nurse is employed by the facility and therefore if the nurse placed the catheter the physician cannot bill for the work of the nurse.

In a facility setting the only services that can typically be billed for the physician or an APP are the services/procedures performed by these providers, anything done by hospital staff should not be billed by the physician or APP as the expense of paying for the hospital staff is part of facility's expenses.
 
If an NP does a routine foley cath change at a patient's home every 4 weeks, can they bill 51702? if they did the change in the PCP's office, can they also charge 51702? Thank you.
 
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