Pediatric Coding Alert

Question: We have recently begun performing in-and-out catheterization on children for urine specimen collection. We are billing with HCPCS code P9612 instead of CPT® 51701. I have been bundling the HCPCS code with an evaluation and management (E/M) service with modifier 25, as the procedure is definitely above and beyond the office visit. Can you tell me why this is not being paid and if I am billing this correctly?

Oregon Subscriber

Answer: The problem here is not from billing the E/M service with 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) and appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). Providing you can show that the catheterization is a separate service, this is the right route to take.

Instead, the issue is with the code used for the procedure. While both 51701 (Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine) and P9612 (Catheterization for collection of specimen, single patient, all places of service) describe the placement of a temporary catheter, the procedures have very different functions: P9612, as the descriptor notes, is for the purpose of obtaining a urine specimen, while 51701 is a diagnostic procedure that helps determine the residual volume of urine left in the bladder after the patient has voided.

So, the correct code to use here would very much be dependent on the purpose of the catheterization. If your pediatrician is attempting a post-voiding residual urine determination (PVR) procedure, then 51701 would certainly be appropriate. But if the purpose of the catheterization is simply to obtain the specimen, then you would use P9612.

Billing note: There is an approximate difference of $45 between the two procedures. Currently, 51701 is being reimbursed at $48.60, while the fee schedule for P9612 is $3.00. So, no payer will reimburse for 51701 — a more complex, minor procedure — if it is being used for a simple lab test.