Urology Coding Alert

Starting point: ‘Indwelling’ detail helps start you in the right direction.

Catheter placement is a common-enough procedure for a urologist to perform, but sometimes even the simplest of procedures merit a coding refresher. Consider this your update on correctly reporting 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]), made easy with real-world advice from some urology experts.

Tip 1: Differentiate 51701 From Other Options

The CPT^® manual includes several codes for catheter placement that might sometimes be appropriate for your urologist’s care. In addition to 51701, you have two other common alternatives:

• 51702 – Insertion of temporary indwelling bladder catheter; simple (e.g., Foley)
• 51703 – ...  complicated (e.g., altered anatomy, fractured catheter/balloon).

Code 51701 normally is used for cases when the physician inserts a non-indwelling catheter to measure residual urine or obtain urine for a culture. You’ll turn to 51702 or 51703 for insertion of an indwelling catheter (such as a Foley catheter) to treat urinary retention or other conditions such as a neurogenic bladder. The appropriate code depends on whether the insertion was complicated (51703) or uncomplicated (51702); your physician’s documentation will point you toward the correct choice.

Watch: Look for documentation of extra work such as the urologist using a catheter guide, passing the catheter over a guide wire, or using a special technique such as using a Council-tipped or Coude catheter as evidence of a complicated insertion. CPT^® code 51703 should also be used for the difficult removal of a Foley catheter and then replacement of the catheter.

Example: The urologist meets a 64-year-old female patient at the hospital; the patient reports burning during urination and pelvic pain. To rule out a urinary tract infection (UTI), the physician performs a bladder catheterization to obtain an uncontaminated urine for culture and sensitivity. Notes indicate that the urologist used a quick catheter kit to obtain the sample using standard sterile technique. No UTI was present.

In this scenario, the quick catheter indicates that the urologist performed a straight catheterization. On the claim, report 51701 for the catheterization. Use R30.0 (Dysuria) appended to51701 as the base diagnosis to represent the patient’s symptom until the diagnosis of a UTI can be confirmed with a positive urine culture, advises Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

Tip 2: Understand Medicare’s Rules

Correct reporting of 51701 can change when you’re submitting a claim for a Medicare patient.

The difference: When the urologist performs straight catheterization for a clean urine specimen for urinalysis or culture and sensitivity, Medicare will not accept 51701. Instead, you should submit HCPCS code P9612 (Catheterization for collection of a specimen, single patient, all places of service). Your bottom line will take a hit since P9612 has a lower reimbursement than 51701, but you must follow the Medicare guidelines.

Caveat: You can, however, report 51701 to Medicare (and commercial/private payers) when the urologist places a catheter for a post-voiding residual urine determination (PVR).

Tip 3: Document Separate E/M

If the service represented by 51701 occurs during an office visit, you can sometimes report the visit in addition to the catheterization – if you have sufficient supporting documentation for the office visit.

Here’s how: Start by ensuring the physician has clear documentation of performing a history, examination and medical decision-making prior to catheterization. Then, show that the E/M service led to your provider’s decision that bladder catheterization was necessary.

Train your providers to write separate office and procedure notes. If you have to appeal for the office visit payment later, having separate documentation will substantiate that the physician couldn’t perform the procedure without the office visit.

Example: A patient presents with fever and a bagged urine specimen that suggests infection. The urologist decides to perform a urine catheterization to obtain a sterile urine sample for urinalysis and culture. The office note should describe the E/M service including the patient’s history of present illness, review of systems, and physical examination findings. The urologist should add his or her assessment, such as “Fever of unknown origin.” Notes outlining the plan of care, such as “Need to do a urine catheterization to obtain an uncontaminated urine sample for urinalysis and culture” should also be in the record.

Write a separate procedure note that includes the pre- and post-diagnoses, findings, and final assessment and plan. For instance, the final assessment might note that the patient has a urinary tract infection. The associated plan would then describe the antibiotic and treatment regime.

Listing the assessment and plan twice shows the payer that the urologist didn’t have a final diagnosis at the E/M service’s conclusion. Therefore, the office visit and examination led to his decision to perform the catheterization.

Tip 4: Include All the Diagnoses and Modifiers

Using different ICD-10-CM codes for the office visit and the catheterization will help support billing both the service and the procedure.

Example:  The urologist sees a patient at 10:30 p.m. for acute urinary retention due to perineal pain after a straddle injury. Report diagnosis S39.848A (Other specified injuries of external genitals, initial encounter) for the perineum injury and link it to the appropriate office visit code (99201-99215). Also report R33.8 (Other Retention of urine) for the urinary retention and link it to 51702.

Modify when needed: If you can show that the E/M service is separate and identifiable from the catheterization, and you have separate documentation for both services, including modifiers will help show the insurer that you should receive separate reimbursement. The two best possibilities are modifier -25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) and modifier -57 (Decision for surgery), the latter modifier used when minor surgical procedures are performed and only for some private/commercial payers.

Modifier -25 informs the payer that the office visit is a significant, separately identifiable service from the catheterization. File the claim with -25, but be aware that some payers will either deny the E/M as included in the catheterization or more likely will include the catheterization in the office visit.

If you find yourself in this situation, resubmit the claim with modifier -57 instead of -25. Modifier -57 often is appropriate for E/M-catheterization encounters for private/commercial payers. For a new patient a urologist would rarely perform a urine catheterization without performing a history, physical examination, and medical decision-making. Since those components lead to the decision for catheterization, modifier -57 could be appropriate.

Tip: Check your major payers’ surgery modifier policies. Call the insurer and ask your representative if the payer wants modifier -25 or modifier -57 on an E/M visit with catheterization.