Pediatric Coding Alert

Question: If pediatricians always perform a catheterization on an infant who needs a clean catch, does that negate the need to document the procedure's medical necessity? Is documenting "Cath ordered and completed" sufficient for an auditor to understand why the physician needs to perform a non-indwelling catheterization?


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Answer: First, pediatricians do not routinely perform catheterizations (51701, Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]). In fact, with infants, pediatricians often perform suprapubic catheter aspirations (51010, Aspiration of bladder; with insertion of suprapubic catheter) instead of catheterizations to obtain a clean urine specimen.

Second, an office nurse may also perform the catheterization if directly supervised by the physician (present in the office and immediately available).

Third, you must always document a procedure's medical necessity. It's your job, not an auditor's, to show why the patient needs the procedure.

You should also document the catheterization as fully as possible to help substantiate separately billing an E/M service in addition to the procedure when appropriate. Make sure you describe the office visit including the medical decision-making that led to the procedure in a separate note, and the full procedure.

Example for a 1-year-old established female patient:

Service:

History - detailed  

1. CC: fever

2. Detailed history of present illness plus pertinent review of systems (ROS) and pertinent past, family, and social history

a. Symptoms: fever, irritability, fussiness

b. Duration of illness: 3 days

c. Home management, including OTC, and response: Tylenol, fever and fussiness continued

d. Additional symptoms: no congestion, cough or vomiting

e. Allergies: none reported

f. Past history: healthy infant, without otitis media

g. Family history: no others ill at home

Physical examination - detailed 

1. fussy, but responsive infant

2. skin clear

3. HEENT: no congestion, tympanic membranes clear, pharynx without erythema, neck supple, without significant adenopathy

4. Chest clear with symmetrical air exchange

5. Heart regular rhythm without murmur

6. Abdomen soft without masses, without tenderness

7. Neurological: alert, irritable, but alert and responsive

Medical decision-making - moderate complexity

1. Assessment: Fever of unknown origin. Bagged urine specimen is questionable 
with 5-10 WBC/HPF (white blood count/high per field).

2. Plan: Decision is made to cath using a non-indwelling catheter for urinalysis and culture. Procedure: Area prepped, catheterization completed without difficulty. Specimen prepared for transport, urinalysis, culture and sensitivity. Preliminary results in 24 hours. Sensitivity results in 48 hours.

Assessment: Infant has a fever and probable urinary tract infection (UTI).

Plan: Initiate intramuscular (IM) antibiotic treatment with Rocephin.
 
Time saver: You should consider building this basic information into a catheterization template. That way, you don't have to write out the full documentation each time. Coding:

 CPT                                                 ICD-9
  99213-25 (E/M service)            780.6 (fever)
  51701 (catheterization)  
  90782-51 (IM) antibiotic injection 
  J0696 (Rocephin)   
  99000 (specimen handling).