Pediatric Coding Alert

CCI makes cath part of LP--nail down the exceptions

A new far-reaching CCI edit could stop your catheterization payment from rolling in unless you act now. Here's when to do so.

Include Related Catheterization in Surgery

The most recent version of the Correct Coding Initiative (CCI), 13.3, bundles catheterization codes 51701-51703 into an astounding 4,638 surgical procedures, including lumbar puncture (62270). The edits are due to nonmutually exclusive standards of medical/surgical practice. You may use a modifier when appropriate to override the edits, which were effective Oct. 1.

Impact: If you use a catheter to obtain a sterile urine specimen and bill a comprehensive surgical procedure on the same day, such as a lumbar puncture (62270, Spinal puncture, lumbar, diagnostic), insurers that implement CCI edits will deny 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) as part of the surgery. "The edits are viewing catheterization as preprocedural work integral to a surgery," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook.

Example: A physician inserts a catheter for urinary drainage in the operating room just before or after a major surgery, such as hernia repair or nephrectomy, because he knows that after the surgery the patient will not be able to get out of bed to use the bathroom. "The catheterization is part of the overall preparation for surgery, just like shaving, so 51701-51703 is a component of these procedures," Ferragamo says.

Separately Bill Cath Unrelated to 62270

But you can still report 51701-51703 when the catheterization is unrelated to the surgery. In pediatrics, this may happen with a fever workup, during which the pediatrician has to use a catheter to obtain a sterile urine sample from a patient (51701) and also performs a lumbar puncture (62270), says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

Example: A 5-week-old girl has a fever of unknown origin (780.6, Fever) requiring a sepsis workup involving a urine catheterization, a lumbar puncture (LP) and high-level hospital admission. Normally, you would code the procedures as 62270 and 51701 and the service with 99223 (Initial hospital care, per day, for the evaluation and management of a patient ...).

Action: When the physician does the catheterization for a reason unrelated to the LP, start adding modifier 59 (Distinct procedural service) to 51701, or insurers may bundle the catheterization with the LP. For instance, in the above case the pediatrician does the catheterization for urine culture and the LP to rule out meningitis. "These really are two separate, distinct procedures," Ferragamo says. So you're justified in overriding the bundle with modifier 59 on 51701 to indicate the catheterization is a distinct procedural service from the LP.

Here's how: You should now bill the 5-week-old girl's encounter as:

• 99223

• 62270

• 51701-59.

Catch: LP involving catheterization during sedation may not qualify for separate billing. If the physician places the catheter for drainage at the time of sedation, the indwelling catheterization, such as 51702 (Insertion of temporary indwelling bladder catheter; simple [e.g., Foley]), is a bundled service, Ferragamo says.

Best bet: Ask, "Why did the pediatrician place the catheter? Is it related to the surgical procedure?" In these cases, you wouldn't unbundle 51701-51702.