Help with CPT code

KaylaRieken

Expert
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I initially attempted to pass a catheter using tactile guidance but I could not advance the tip beyond the meatus. I then prepped the patient and performed bedside cystoscopy. Consent was obtained. I was able to visualize the head of the penis and meatus with the assistance of the cystoscope. With some difficulty I was able to advance a straight Sensor wire through the meatus into the bladder. The scope was withdrawn. I first attempted to pass a 16 French Council tip catheter over the wire but resistance was met at the meatus. I then attempted to pass a 12 French catheter over the wire, but resistance was met again. This was consistent with meatal stricture likely following his prostate surgery and catheterization. I attempted to dilate the urethra at bedside, however the patient did not tolerate an attempt at passing a 12 French dilator so the procedure was stopped.

What should I code this as?
 

liqgold2@aol.com

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From you question it does not seem as if you were able to do any dilation of the stricture at all. Don't bill for a dilation. If you were able to see part of the urethra by urethroscopy, then bill 52000-52 for the reduced service. If not, bill an appropriate E/M service on what else you did or bill on the time you spent with the patient. The latter would seem to be the best way to code for this clinical scenario.
 
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