Primary Care Coding Alert

Question: A charge ticket indicates the FP performed an "in & out cath." Diagnosis is dysuria (788.1.) In the 51700-51703 range, which CPT code should I use?

Montana Subscriber

Answer: You should submit 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]). The FP in this procedure inserts a non-indwelling catheter to obtain residual urine. An "in & out cath" suggests putting the catheter in and immediately removing it, which falls under non-indwelling catheter.

Procedure documentation might also describe whether the physician placed the catheter with or without difficulty, the measurement of return from the catheter, and if she removed the catheter with or without complications.

If the physician inserts a catheter into a patient's bladder and allows the device to remain in place, you would use 51702 (Insertion of temporary indwelling bladder catheter; simple [e.g., Foley]) or 51703 (... complicated [e.g., altered anatomy, fractured catheter/balloon]). Submit an uncomplicated insertion as 51702 and a complicated insertion as 51703.

Physicians often use an indwelling catheter, such as a Foley catheter, to treat urinary retention (such as 788.20, Retention of urine, unspecified) or neurogenic bladder (for instance, 596.54, Neurogenic bladder NOS). Dysuria code 788.1 represents "difficulty or pain in urination," a common symptom of a urinary tract infection. If the patient cannot provide a clean sample, the physician -- or more typically a nurse -- may have to insert a catheter to obtain a sample.

Instillation or irrigation (51700, Bladder irrigation, simple, lavage and/or instillation) is the placing of a therapeutic agent, such as medication, to treat interstitial cystitis (595.1, Chronic interstitial cystitis).

Answers for You Be the Coder and Reader Questions reviewed by Kent Moore, director of financial accounting for the American Academy of Family Physicians in Leawood, Kan.