Urology Coding Alert

Coding any underlying conditions causing the retention is key.

When a patient visits your urology office experiencing urinary retention, having the urologist find the solution quickly and correctly coding it on your claim are both crucial. Because there can be a variety of causes for urinary retention and tests may be ordered to find that solution, coding can easily become confusing.

Read on to find out how to submit clean urinary retention claims in your urology practice.

Understand the Difference Between Acute and Chronic Retention

Acute urinary retention is the sudden and painful inability to urinate, which may require emergency intervention. Acute or short-term urinary retention can occur for a number of reasons, such as a side effect from drugs with anticholinergic activity (for example, antidepressant and antipsychotic medications), calcium channel blockers, opioids and anesthetics, benzodiazepines, and nonsteroidal anti-inflammatory drugs (NSAIDs), or as a temporary side effect after anesthesia.

Chronic urinary retention is a long-term condition. Patients suffering from chronic urinary retention may experience varying forms of incontinence or may feel the urge to urinate more frequently than normal. There are several reasons patients may experience chronic urinary retention, including nerve problems resulting from stroke, diabetes, or multiple sclerosis; they also may have weak bladder muscles due to age, or there may be a blockage in the urinary tract.

The most common ICD-10-CM code choices for urine retention are as follows:

• R33.0 (Drug induced retention of urine)
• R33.8 (Other retention of urine)
• R33.9 (Retention of urine, unspecified)
• R39.14 (Feeling of incomplete bladder emptying).

Know When a Urodynamic Study Is Needed

When the cause of a patient’s urine retention is unclear, or the standard treatments have been ineffective, a urodynamic study may be necessary. Providers use this study to assess how well the bladder and urethra are storing and releasing the urine, and it may give more insight into the cause of the retention. The test is performed by inserting a catheter and filling the patient’s bladder to capacity with water to test the different levels of pressure during filling and emptying. This test is called a cystometrogram (CMG).

To code for this testing, you will look to the following CPT^® codes:

• 51725 (Simple cystometrogram (CMG) (eg, spinal manometer)): A simple CMG uses a spinal manometer to determine bladder pressures and is rarely performed as a single procedure.
• 51726 (Complex cystometrogram (ie, calibrated electronic equipment)): This service is a complex CMG where a urologist fills the patient’s bladder through a catheter and measures the pressures with complex CMG-calibrated electronic equipment.
• 51727 (… with urethral pressure profile studies (ie, urethral closure pressure profile), any technique): If your provider also performs a complex CMG, fills the patient’s bladder through a catheter, measures the pressures with complex CMG-calibrated electronic equipment, and performs a urethral pressure profile (UPP), you should report this code. You should also bill 51727 for a complex CMG and a Valsalva leak point pressure (VLPP) in place of a UPP.
• 51728 (... with voiding pressure studies (ie, bladder voiding pressure), any technique): You should report this code when your urologist performs a complex CMG with voiding pressure studies using any technique.
• 51729 (... with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique): When your urologist performs a complex CMG with voiding pressure studies and UPP using any technique or VLPP, you should report 51729.
• 51741 (Complex uroflowmetry (eg, calibrated electronic equipment)): Uroflowmetry is a measure of how much liquid the patient excretes from their bladder.

If your urologist performs a radiological voiding study in addition to a complex urodynamics study, you may also report the following codes on your claim:

• 51600 (Injection procedure for cystography or voiding urethrocystography)
• 74455 (Urethrocystography, voiding, radiological supervision and interpretation)

Test Your Urinary Retention Coding Skills

Procedure notes: The patient arrived at our office today suffering from acute urinary retention due to a urethral injury. A few days post-bladder stone removal surgery, the patient was attempting to change their own catheter at home and injured themselves during the process, leaving them unable to urinate and unable to insert the catheter comfortably. How would you code this?

Answer: The patient came to the office for the urine retention, so you will code this first using ICD-10-CM code R33.8. Since the patient injured themselves placing a catheter for medical reasons, you’ll also need to add code S37.30XS (Unspecified injury of urethra, sequela). Depending on your payer, you may wish to add a code to represent the reason for the injury. In this case, you would assign Y73.3 (Surgical instruments, materials and gastroenterology and urology devices (including sutures) associated with adverse incidents) to your claim.

Make note: A Code first note under code R33.8 instructs you to report a causal condition code first if it applies, but there was nothing to add in this scenario.

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