Wiki Coding 51703 with 53600

[01084223]

The patient has had multiple strictures in the past. He presents for another procedure (heart cath) and needs a foley catheter placed. The urologist documents his "plan" is for difficult catheterization.

Procedure Note:
The patient was prepped and draped in the sterile fashion with Betadine and 2% Xylocaine instilled into the urethra. The hangman stylet was negotiated into the bladder. This is somewhat difficult. This gentleman is dilated with sounds to an 18 F and we have placed a 16F Foley into the bladder


Does this documentation support billing for both 51703 and 53600?

 

[Kelly_Mayumi]

Hmm, that's difficult to decide. In my opinion, it sounds like the urethra was dilated to pass the catheter vs treating a stricture. If this is the case, I'd just bill 51703.