Urology Coding Alert

Question: The urologist documented the following: "At the end of the procedure, a 16-French Council-tipped catheter was placed per urethra in the bladder with 10 ml of sterile water balloon." This patient also had a cystoscopic examination with removal of another catheter as well as a Foley catheter insertion. Should I code for this catheter insertion, or will payers consider it integral to a procedure?

Missouri Subscriber

Answer: You should report a Council-tipped catheter insertion with 51703 (Insertion of temporary indwelling bladder catheter; complicated [e.g., altered anatomy, fractured catheter/balloon]). But if the urologist inserts a Council-tipped catheter after a cystoscopic examination (52000, Cystourethroscopy [separate procedure]), payers will consider 51703 bundled into the cystoscopic procedure.

Therefore, in this case, you should not report 51703 separately, even with a modifier.