Urology Coding Alert

Question: What code can we use for the removal of a urethral/ bladder catheter?

Hawaii Subscriber

Answer:

There is no CPT Code for the simple uncomplicated removal of a urethral catheter. You will include the removal in the E/M code you report for the patient visit. For example, you might report 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) for a level-three office visit with an established patient for the E/M and the catheter removal.

Exception: If your urologist could not remove the urethral catheter because of a defective balloon, which cannot be deflated, and he needs to perform ancillary measures to remove the catheter, you can report 51703 (Insertion of temporary indwelling bladder catheter; complicated [eg, altered anatomy, fractured catheter/balloon]). You should report 51703 regardless of whether or not the urologist reinserted a new catheter. Ancillary measures to remove the catheter would include cutting the inflation limb of the catheter, passing a wire up the inflation limb and breaking the valve and thus draining the balloon, or percutaneous needle drainage of the balloon.