Part B Insider (Multispecialty) Coding Alert

Question: How should I code for removal of a retained Foley catheter balloon when the office visit also includes bladder irrigation and clot removal? This procedure was followed by a hospital admission a few weeks after the patient had ESWL.


Michigan Subscriber


Answer: No matter what means the doctor used to remove the Foley catheter, report 51703 (Insertion of temporary indwelling bladder catheter; ...) advises Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook.

Also report 76942 (Ultrasonic guidance for needle placement ... imaging supervision and interpretation) for ultrasonic guidance use.

Important: Ultrasound guidance isn't considered part of 51703, so you don't have to bundle with 76942.

Option 1: Coding the office visit and the hospital admission depends on whether the urologist saw the patient in the hospital on the admission date, Ferragamo continues. Report the appropriate-level office visit code (99201-99215) when the urologist admits a patient to the hospital from the office but doesn't see the patient in the hospital that day. Then use the E/M service code that reflects where the physician delivered services.

Option 2: When the office visit and the initial hospital care occur on the same day, you should roll both services into one E/M code, according to Ferragamo. If the urologist also saw the patient in the hospital after the patient was admitted on the same day as the office visit, combine the office visit and initial inpatient hospital care into one hospital E/M code (CPT 99221 -99223).

Translation: When the initial hospital care date coincides with the admission date, consider all related E/M services that the physician provides on that day part of initial hospital care and submit only the initial hospital care codes.