Wiki Retrograde urethrogram

chicksangelbaby2

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I am hoping I am posting in the correct area but I was wondering if someone could help me code this I am looking at code 51610 or 52776. would I use both 76 and 52 modifiers?

Thank you for any help given!!
Cathy



POSTOPERATIVE DIAGNOSIS: Perineal trauma.

PROCEDURE: Retrograde urethrogram x2.

WHAT WAS DONE: This 26-year-old came in with significant perineal trauma after being a pedestrian struck. While there were no fractures, there was bruising of the meatus and significant scrotal hematomas and abrasions as well as a scrotal laceration and an inner left thigh laceration. The patient was then unable to void spontaneously and so after the usual prep and drape under sterile technique, a Foley catheter was inserted about 2 cm into the urethra and the balloon slightly inflated and Omnipaque used to infuse the urethra. On the 1st attempt the catheter slipped out of the meatus and there was apparent lack of contrast flow beyond the distal urethra. So this was done a 2nd time and again there was opacification only of the urethra distal to the prostate. Therefore, the procedure was terminated at this point, and Urology consultation was under undertaken.
 
I could not locate the code 52776 in my CPT book or the 3M coder.

I would use 51610 and the S & I code 74450. I do not feel that mod 52 is necessary because the code is for evaluating the urethra, which was done.
 
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