Urology Coding Alert

Question: I’m confused about whether to report a procedure as a complicated catheter change. Our urologist used implant dilators to dilate the urethral opening and diffuse urethral strictures throughout the ureter. He noted that “this was quite difficult.” The patient was in enough discomfort to need morphine and Versed to help tolerate the dilation. Notes state that the dilation “was quite firm and rigid throughout the urethra.” After the urologist was able to dilate sufficiently, he “made a council-tip catheter out of a 14-French catheter by passing the needle through the tip and then passing this over the Glidewire.” This advanced easily and clear urine was obtained. The balloon was inflated with sterile water and connected to gravity drainage. After emptying approximately 400 mL, the urologist clamped the bag and asked the nurse to release in 15 minutes.

The diagnoses are urinary retention and urinary stricture. How do I code all of this? Would 53601 and 51703 both apply?

West Virginia Subscriber

Answer: Even with all the steps in the procedure, the only code you should report is 51703 (Insertion of temporary indwelling bladder catheter; complicated…) since the insertion was complicated by the altered anatomy of the urethral stricture. The work of 53601 (Dilation of urethral stricture by passage of sound or urethral dilator, male; subsequent) is not separately billable because the dilation is part of the 51703 service.

Special note: When you look at Correct Coding Initiative edits, 51703 and 53601 are paired with 51703 as the Column 2 code. You are allowed to bill only 51703 in this situation because of the complicated insertion.