Urology Coding Alert

Question: I have run into some notes that state that the physician performed a retrograde urethrogram with fluoroscopic interpretation.  I have seen where some coders automatically bill code 51610 with 74450 and some only code 51610 since the fluoroscopy would bundle into the code.  What is the correct way to report this procedure? Also, if the physician only mentions findings in the note but doesn't state that he interpreted, can we bill for the interpretation along with the procedure?

Missouri Subscriber

Answer: You are correct that 51610 (Injection procedure for retrograde urethrocystography) is the proper code for the procedure of injection of contrast material into the urethral meatus in a retrograde fashion to delineate the whole urethra and bladder radiologically.

You should report the interpretation of this study -- reading the X-ray films -- using 74450 (Urethrocystography, retrograde, radiological supervision and interpretation).

If urologist reads the films of this study, he may bill for the radiological interpretation. However, to bill and receive payment, 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 such as one that may be reported by a radiologist.

Remember: If the study and reading are performed in a facility such as a hospital, add modifier 26 (Professional component) to 74450 for billing only for the interpretation. The technical portion of the fee will be paid to the hospital as they own the equipment, pay for the technician, and contrast material used.

You are also correct that fluoroscopy (76000) is included in the above two codes and should not be billed separately.