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Coding 51703 with 53600

  1. Default Coding 51703 with 53600
    Medical Coding Books
    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?

  2. Default
    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.

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