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Focus on technique and placement is key.

It’s crucial to meticulously review the medical records when your urologist performs catheterization procedures. Details such as the type of catheter used, the reason for the catheterization, and the presence of any complications or associated conditions should be carefully noted. Additional procedures or work related to the catheterization should also be accounted for. How prepared are you to code these procedures?

Test your knowledge by reviewing the scenarios below.

Code This Complex Catheter Insertion

Scenario 1: This patient had a right (RT) total knee arthroplasty (TKA) and developed acute urinary retention immediately after surgery, so he was unable to urinate. A straight catheter was unsuccessful, as he was found to have a bladder neck contracture.

Procedure notes: Patient was prepped and draped in the usual sterile fashion. Spinal anesthesia was still active from his RT TKA, so no local anesthesia was necessary. Catheter insertion: temporary indwelling, catheter type: Foley, catheter size: 12 Fr. Complicated insertion: yes. Altered anatomy: yes, due to bladder neck contracture. Comments: Inserted 0.35 sensor wire into bladder without resistance. Dilated with 10F, 12F, 14F, clear urine began to drain. Unable to pass 16F dilator. 12F silicone catheter transitioned into council tip with 16F angiocath and placed over wire into bladder with no resistance. 1L of clear yellow urine was extracted. Keep Foley to gravity. Discharge home with Foley.

Answer 1: You should code this procedure as 51703 (Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon)). Here’s why.

The main reason for the urologist’s participation in the patient’s care was for the catheter insertion for residual urine resulting from urinary retention after the surgery, according to John Piaskowski, CPC-I, CPMA, CUC, CRC, CGSC, CGIC, CCC, CIRCC, CCVTC, COSC, specialty medicine auditor at Capital Health in Trenton, New Jersey and surgical coding consultant at Memorial Care Health System in Huntington Beach, California.

The procedure was “hindered by abnormal anatomy — false passages and a bladder neck contracture” — making the procedure the urologist performed complicated, eliminating the other Foley catheter code, 51702 (… simple (eg, Foley), which you would use for a simple insertion, Piaskowski says. As the catheter the urologist inserted was a temporary indwelling catheter and not a straight catheter, this would also eliminate using 51701 (Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine)).

Don’t bundle the dilation: In this encounter, “the dilation portion of the service was only performed to facilitate the successful insertion of the catheter and is an included component of the primary service,” according to Piaskowski. So, you would not code the dilation separately.

Explore This Endoscopic Example

Scenario 2: The physician performed an endoscopic examination of a patient’s ileovesicostomy using a flexible cystourethroscope. During the procedure, a catheter was placed in the ileovesi­costomy to help with urine flow. One end of the catheter was stitched to the bladder, while the other end of the catheter was fastened with a button on the front of the abdominal wall. The catheter’s position was secured.

Answer 2: From the information supplied, this patient had an ileovesicostomy, a type of urinary diversion, where a portion of the small intestine (ileum) was removed and used to create a new tube or channel from the top of the bladder to the outside of the skin on the abdomen, known as a stoma. Therefore, the urologist performed a cystourethroscopic examination via this conduit between the skin and bladder.

“CPT^® code 52005 [Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service] would be the appropriate coding choice because in the operative notice, a catheter was implanted in this patient,” says Stephanie Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime urology coding expert and consultant in Glen Burnie, Maryland. Per the guidelines, “Because cutaneous urinary diversions utilizing ileum or colon serve as a functional replacement of a native bladder, endoscopy of such bowel segments, as well as performance of secondary procedures, can be captured by using the cystourethroscopy codes,” says Storck.

Don’t Sell This Complicated Foley Placement Short

Scenario 3: The patient is suffering from urinary retention.

Procedure notes: 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.

Answer 3: 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 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.

Take note: 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.

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC