ED Coding and Reimbursement Alert

Question: We have purchased a bladder scanner to be used in the emergency department. The physician will perform the bladder scan with a small hand held bladder ultrasound scanning device. The physician wants to do a pre- and post-void ultrasound.  Would reporting 51798 once accurately describe both the pre- and post-void? Or can we charge for both?
   
Minnesota Subscriber

Answer: Your best bet is to report just one unit of 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging), though it specifically describes measurement of post-voiding residual urine and bladder capacity.
 
In the 2003 edition of CPT Changes , there is a clinical example of a patient who is scanned immediately after the patient voids. The physician measures residual urine volume and encourages the patient to try again. He then rescans the patient and measures the urine volume again. In your example, however, there are multiple scans. The pre-void scan might be considered by some payers to represent the bladder capacity - and the code contains the wording "bladder capacity and/or post void residual" - so reporting one unit of 51798 may be appropriate.

-Reader Questions and You Be The Coder reviewed by Michael A. Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems, Inc. in Stoneham, Mass.