Internal Medicine Coding Alert

Question: The internist meets a 64-year-old female patient at the hospital; the patient reports burning during urination and pelvic pain. To rule out a urinary tract infection (UTI), the physician performs a bladder catheterization. Notes indicate that the physician used a quick catheter kit to obtain the sample using standard sterile technique. No UTI was present. What is the code for this procedure?

Michigan Subscriber

Answer: The quick catheter indicates that the physician performed a straight catheterization. On the claim, report the following:

• 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) for the catheterization

• 788.1 (Dysuria) and 625.9 (Unspecified symptom associated with female genital organs) appended to 51701 to represent the patient's symptoms

• modifier 26 (Professional component) appended to 51701 to show you are only coding for the professional portion of the procedure.

Note: Use 51701 only for non-indwelling catheter procedures. If the physician inserts an indwelling catheter (such as a Foley catheter), report either 51702 (Insertion of temporary indwelling bladder catheter; simple [e.g., Foley]) or 51703 ( ... complicated [e.g., altered anatomy, fractured catheter/balloon]).