Urology Coding Alert

Question: How should I report this Foley catheter procedure? The patient had urinary retention. The procedure report reads:

The patient was prepped and draped in usual sterile fashion. A 16 French Foley and 18 French coudé were not able to be passed through the urethra. Sensor wire and glidewire were attempted without success. Eventually I elected to switch to the bedside flexible cystoscope. Cystoscopy was very difficult due to the uncircumcised nature of the phallus as well as long penile urethra. A large false passage was noted. Eventually, I was able to locate a pinpoint urethral opening, 3 mm in diameter, which looked almost like a stricture. This was cannulated with a wire. I then placed an 18 French council catheter over the wire. There was efflux of clear yellow urine. 10 cc of sterile water were inflated into the balloon. The catheter was hooked up to a drainage bag. Catheter was then secured to the patient’s leg.

AAPC Forum Member

Answer: Since your urologist placed the Foley catheter to treat urinary retention and needed to use cystoscopy to complete the placement, you should report 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female).

Even though your urologist did not visualize the bladder, they still inserted the cystoscope and attempted to dilate the stenosis (documented as a pinpoint opening of 3 mm diameter), then placed the Foley catheter to reduce the retention.

This is more than just a diagnostic study — which you would be code with 52000 (Cystourethroscopy (separate procedure)) and more than just a difficult Foley placement (51703, Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon)) due to the cystoscopy.

Warning: There is a National Correct Coding Initiative (NCCI) edit that prevents you from reporting catheter insertion codes 51701, 51702, and 51703 with most procedures. In this case, NCCI bundles 51701, 51702, and 51703 into 52281 with a “0” modifier indicator, which means you can never unbundle them.