Urology Coding Alert

Question: Which CPT^® code would I choose for this catheter placement? 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: 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 to home with Foley.

Texas Subscriber

Answer: 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 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.