Pediatric Coding Alert

Question: A child has a fever of unknown origin. The pediatrician performs a urine catheterization to obtain a clean urine sample. How should I report the established patient encounter? Will I need a modifier to get the insurer to cover the E/M service?

New York Subscriber

Answer: CPT Codes 2003 created new code 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) for catheterization to obtain a clean-catch urine sample. Unlike deleted code 53670 (Catheterization, urethra; simple), 51701 is not a starred procedure.

To separately report the office visit, the pediatrician now must perform a significant, separately identifiable service. For instance, if the child presents with a fever of unknown origin (780.6) and the pediatrician needs the catheterized urine sample and doesn't do anything else, you should charge only for the surgical procedure (51701).

Prior to obtaining the urine sample, a pediatrician usually performs a history, examination and medical decision-making. In this case, you should separately report the office visit (usually 99213-99214, Office or other outpatient visit for the evaluation and management of an established patient). To indicate that the office visit is a significant, separately identifiable E/M service from the minor E/M service included in the catheterization, append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the office visit code. Link 780.6 to 51701, and link any other symptoms, such as vomiting (787.03, Vomiting alone) and/or diarrhea (787.91), to 99213-99214-25. Although technically unnecessary, depending on payer, different diagnoses will bolster your case that the E/M and catheterization are separate procedures. If your payers reject the E/M code appended with modifier -25, you may also try using modifier -57 (Decision for surgery) on 99213-99214. Because CPT guidelines do not designate minor and major surgeries, some payers may recognize modifier -57 with a minor surgical procedure, such as 51701.