Urology Coding Alert

Don’t rush to judgement until you’ve got all the facts.

Every surgical specialty has a set of staple procedures that seasoned coders know like the back of their hand. While the coding processes are typically second nature, scenarios involving these procedures are also easy to overlook — until one ventures off the beaten path.

Today, you’re going to address an indwelling bladder catheter insertion with a few more moving parts than what initially meets the eye.

Put your skills to the test and keep your guidelines close by as you work your way through this tricky catheter insertion example.

Try on This Scenario for Size

Example: A patient with acute urinary retention (AUR) resulting in lower urinary tract obstruction receives an emergency urethral catheterization in order to decompress the bladder. The Foley catheter is left in place and the patient is transferred to outpatient care. A subsequent ultrasound (US) scan of the urinary bladder interpreted by the treating urologist reveals that the underlying cause of the AUR is benign prostatic hyperplasia.

The emergency services performed to treat this patient’s urinary tract obstruction are relatively straightforward. Using the CPT^® index, Catheter/Catheterization ⇒ Bladder ⇒ Insertion narrows your choice down to the following codes:

• 51701 (Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine))
• 51702 (Insertion of temporary indwelling bladder catheter; simple (eg, Foley))
• 51703 (Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon))

Since you have documentation supporting that the catheter remained in place, you can immediately rule out code 51701. Your choice between codes 51702 and 51703 depends on whether the surgeon encountered any underlying difficulty placing the catheter. The code description for 51703 outlines a few scenarios that might result in the provider opting for increased reimbursement due to the degree of difficulty of the procedure.

Gain Deeper Insights on 51703 Coding

Melanie B. Scott, CPC, CPPM, CMPE, director of operations at Five Valleys Urology in Missoula, Montana, outlines one clinical scenario that warrants reporting of 51703. “While most of the catheter changes in a clinical setting are routine or simple, every so often our staff has to ask a provider for help. This happens when the patient has previously had an injury to the urethra that might have caused scar tissue or a stricture, or possibly when a false passage was created by a prior attempt to place a catheter,” Scott explains.

However, Scott warns that the mere act of requesting the provider’s help should not automatically result in billing a complicated catheter insertion. “If the provider places the catheter without any issues we will still bill for a simple insertion. Only the physician can make the determination of difficulty and should subsequently document the degree of difficulty encountered to support the complicated catheter placement,” Scott instructs.

Home in on a Few Key Guidelines

Unless the operative report fully elaborates on any confounding variables impacting the procedure, you should report code 51702 for the catheter placement. Next, you must decide upon the correct code for the US of the bladder. Since only one organ was imaged, you can rule out 76770 (Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete). As the CPT^® code book explains, you’ve got to have documentation of the kidneys, abdominal aorta, common iliac artery origins, inferior vena cava, and any other demonstrated retroperitoneal abnormality in order to report a complete retroperitoneal US code. When that criteria isn’t met, or the scan homes in on a single organ or quadrant, you’ll report the limited code 76775 (… limited). You’ll also want to make sure you append modifier 26 (Professional Component) to 76775 to identify to the payer that the urologist only interpreted the scan, but does not own the equipment in the hospital.

Now that you’ve got your codes, the last step you should always make yourself accustomed to is performing a National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits check between 51702 and 76775. You’ll find an existing modifier indicator of “1” between these codes, with 51702 being the column 2 (and lower-valued) code. While these codes can be unbundled using modifiers 59 (Distinct Procedural Service) or X{EPSU}, you’re going to need a little more information before making a final verdict. That’s where the NCCI Policy Manual comes into play.

If you scour Chapter 7 (CPT^® codes 50000-59999) of the NCCI Policy Manual, you may think you’ve found everything you need to finally send this claim off to the payer. There are multiple mentions of code range 51701-51703. Some of these guidelines explain that since code range 51701-51703 is included in the global surgery package, you should not report 51701-51703 when performed alongside, or just prior to, another surgery. The manual further adds that 51701-51703 is included in the global surgery package. Therefore, it’s not to be reported alongside procedures with a global period of 000, 010, or 90 days.

Leave No Stone Unturned

Since a retroperitoneal US is not a surgery and subsequently is not designated global days, you could reasonably conclude with this information at hand that 51702 and 76775 may be reported together with an unbundling modifier — but not so fast. When considering unbundling codes with a designated modifier indicator of “1,” you should make it habit to read through each of the codes’ respective NCCI Policy Manual chapters, if different. This means examining all the relevant NCCI guidelines within Chapter 9 (CPT^® codes 70000-79999).

If you’re short on time and want to find what you’re looking for quickly, you might have picked up the habit of pressing ctrl + F and typing in the specific code or code range you’re looking for. While certainly a timesaving technique, you’ll find that it’s not always effective — as in the case of this example. Searching for 76770 and/or 76775 will highlight a few sets of otherwise important guidelines, but none relevant to this coding example. However, if you make your way to section D (Interventional/Invasive Diagnostic Imaging), you’ll come across the following guideline that changes the coding fabric of this increasingly nuanced scenario.

The NCCI Policy Manual guidelines state that “When urologic radiologic procedures require insertion of a urethral catheter (e.g., CPT^® code 51701-51703), this insertion is integral to the procedure and is not separately reportable.” This excerpt provides you with an unequivocal answer to your coding question: Code 51702 should not be reported alongside 76775-26. No overriding modifier is appropriate in this instance.

Note: “Keep in mind that there are in-office clinical settings that allow you to code in 51702 with 76857 [Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles)] for the bladder sonogram, with which you’ll append modifier 59 or -X{EPSU} to the lower-valued code [76857],” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook.