Radiology Coding Alert

Question: The physician performed a retrograde urethrogram with fluoroscopic interpretation. What is the correct way to report this procedure?

Missouri Subscriber

Answer: Code 51610 (Injection procedure for retrograde urethrocystography) is the proper code for the surgical portion, which includes injection of contrast material into the urethral meatus in a retrograde fashion to delineate the whole urethra and bladder radiologically.

You should report the radiological services for this study using 74450 (Urethrocystography, retrograde, radiological supervision and interpretation).

A complete written interpretation should be included in the medical records. The reading should include the type and size of the catheter used for the injection, the amount, name and concentration of contrast material used, and a formal full reading of the study.

Remember: If the study and reading are performed in a facility such as a hospital, add modifier 26 (Professional component) to 74450 to bill only the physician's services. The technical portion of the fee will be paid to the facility because they bear the cost of the equipment, the technician, and contrast material used.

The service: Retrograde urethrocystography involves the insertion of a catheter into the urethral opening. Contrast is injected through the catheter into the urethra and followed as it flows retrograde into the bladder. The radiologist looks for the presence of abnormalities in the urethra and the bladder as well as any passive reflux of contrast flowing backward into the ureter, which connects the kidneys with the bladder.