Urology Coding Alert

Question: My doctor is trying to stump me with "suprapubic needle insertion to pop Foley catheter, using ultrasound guidance for needle placement." This was done in the office for a patient with neurogenic bladder. How should I code this?


California Subscriber

Answer: There are a few parts to coding this procedure. First, you should report 51703 (Insertion of temporary indwelling bladder catheter; complicated) for the complicated removal of the Foley catheter. Use this code for difficult removal of a catheter, whether or not a new one is inserted. Report 51703 regardless of the method the urologist uses to remove the Foley catheter, including when he uses a needle to break the balloon as in this case.

You should also report 76942 (Ultrasonic guidance for needle placement, imaging supervision and interpretation) because the urologist performed ultrasonic guidance during the procedure. Although the National Correct Coding Initiative bundles 76942 into bladder surgery codes 51705 (Change of cystostomy tube; simple) and 51710 (... complicated), 76942 isn't bundled with 51703.

If the urologist provided any type of E/M service, you can report the appropriate code for that service as well, but remember to add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

For the primary diagnosis, use 996.31 (Mechanical complication of genitourinary device, implant, and graft, due to urethral [indwelling] catheter). For a secondary diagnosis, use 596.54 (Neurogenic bladder NOS) for the urologist's conclusion that the patient also has a neurogenic bladder.