Radiology Coding Alert

Question: The radiologist performed a limited cystogram for a patient status post prostatectomy to determine whether the Foley catheter was in the bladder. She documented that "contrast was injected through the patient's indwelling Foley catheter. This showed partial filling of the urinary bladder. After approximately 25 percent filling of the bladder, contrast was seen to pass around the Foley catheter balloon into the urethra. Extensive spillage of contrast from the urethra into the surgical bed was seen, with contrast opacification of the patient's surgical drain seen."

Ohio Subscriber

Answer: You should report 51610 (Injection procedure for retrograde urethrocystography) and 74450 (Urethrocystography, retrograde, radiological supervision and interpretation) for the procedure you describe.

Don't miss: Experts suggest appending modifier 52 (Reduced services) to 51610. Reason: Code 51610 includes putting the catheter into the bladder, but this patient already has a catheter in place.

Term tip: A urethrocystography is a radiographic examination of the urethra and bladder. The physician performs the procedure by filling the bladder during retrograde urethrography.

You can tell that the service was retrograde (against the flow) because the injection was through the Foley.