EM Coding Alert

Reader Questions:

Look at Black and White Results in This Clinical Urology Scenario

Published on Thu Jul 22, 2021

Question: My physician initially attempted to pass a catheter using tactile guidance but could not advance the tip beyond the meatus. He prepped the patient and performed bedside cystoscopy. Consent was obtained. He was able to visualize the head of the penis and meatus with the assistance of the cystoscope. With some difficulty, he was able to advance a straight Sensor wire through the meatus into the bladder. The scope was withdrawn. He first attempted to pass a 16-French Council tip catheter over the wire, but resistance was met at the meatus. He then attempted to pass a 12-French catheter over the wire, but resistance was met again. This was consistent with meatal stricture likely following the patient’s prostate surgery and catheterization. My physician 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 code should I report for this procedure?

AAPC Forum Subscriber

Answer: From the information your provided, it does not seem as if the physician was able to do any dilation of the stricture at all. So, you shouldn’t bill for a dilation. If the physician was able to see part of the urethra by urethroscopy, you could bill 52000 (Cystourethroscopy (separate procedure))-52 (Reduced services) for the reduced service. If not, you should bill an appropriate evaluation and management (E/M) service on what else the physician did or bill on the time the physician spent with the patient. The latter would seem to be the best way to code for this clinical scenario.