Radiology Coding Alert

Question: When reporting a voiding cystogram, can we also report for contrast injection? Our physician documented as follows:

‘The patient’s bladder was catheterized using standard sterile technique. Water-soluble contrast was instilled via gravity.’

Is there a different code for contrast instillation when it is done under the effect of gravity?

Massachusetts Subscriber

Answer: You report code 74455 (Urethrocystography, voiding, radiological supervision and interpretation) for the voiding cystogram and code 51600 (Injection procedure for cystography or voiding urethrocystography) for the contrast injection. You can bill for CPT® code 51600 when the physician injects a radioactive contrast agent through a catheter inserted in the bladder to study the lower urinary tract. Your Physician must document this in the chart in order for it to be coded and billed. CCI does not bundle these two procedures (74455 and 51600) and you can report the two together and earn for each one of them.

It isn’t clear what your physician wants to specify by including the term ‘gravity’ for the contrast injection. You may like to seek a clarification from your physician for this. However, the code 51600 is used for the contrast injection into the urinary tract. Such an injection is given via the urethral opening. There is no differentiation of ‘under effect of gravity’ or ‘retrograde’ injection of contrast.