Urology Coding Alert
Only Report What’s Documented
Question: If the documentation just stated that my urologist inserted a Coude catheter, can I report codes 51798 and 51703 together? AAPC Forum Member Answer: If your urologist documented both 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging) and 51703 (Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon)), then you can bill for both services. However, if your urologist only documents the placement of the Coude, you should just bill 51703. If your urologist does not document a service performed in the medical record, you cannot report it even if you believe it was performed but not documented by your urologist.
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