Primary Care Coding Alert

Question: The FP performs a suprapubic aspiration to obtain a clean urine specimen from an inpatient infant who is suspected of having sepsis. Should I code the procedure with 51701?

Ohio Subscriber

Answer: No. You should report this procedure as a bladder aspiration, not as a catheterization. Code 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) describes insertion of a non-indwelling catheter through the urethra into the bladder to collect residual urine for urinalysis and culture. A nurse can perform this procedure in the office under direct physician supervision.

To obtain urine from an infant younger than 6 months, an FP may instead use suprapubic bladder aspiration. In this collection technique, the doctor withdraws urine from the bladder into a syringe through a needle inserted through the skin into the bladder.

In 2008, you should report this procedure with 51100 (Aspiration of bladder; by needle). This code replaces 51000, which CPT inappropriately placed under the "Bladder, Incision" subheading in the "Urinary System" subsection, according to CPT Changes 2008 -- An Insider's View.

In CPT 2008, the AMA relocated the code to a new "Removal" subheading subsection and renumbered it.