toria11
Guru
Please see the ED visit below. The urologist wants to bill 51703 along with the E/M visit. I don't think it's correct to bill for an attempted catheter placement that was not successful. Thoughts?
HISTORY OF PRESENT ILLNESS:
The patient is an 85-year-old male with BPH. Apparently, he was seen recently in the emergency room for a catheter placement, which failed. He was seen by Dr. R*** who performed cystoscopy with placement of a catheter. The patient saw his regular urologist, Dr. H*****, today who decided to remove the catheter. He now comes to the ER not having voided in the past 8 hours. He is not uncomfortable. PVR in the ER was 370 mL. Bladder scan in the ER was 370 mL.
PAST MEDICAL HISTORY:
Positive for BPH, coronary artery disease, prior TURP, leukocytosis, overactive bladder, pacemaker, Parkinson's, atrial fibrillation.
REVIEW OF SYSTEMS:
As dictated above.
PHYSICAL EXAMINATION:
GENERAL: He is an afebrile male lying comfortably in bed. No apparent distress.
HEENT: Normal.
LUNGS: Clear.
COR: S1, S2 normal.
ABDOMEN: Benign. No bladder distention.
EXTREMITIES: Normal.
PROCEDURE:
The patient had undergone several prior attempts to pass a catheter by the emergency room staff. I was called to see if I could get it in place. I tried both a 12-French and a 14-French coude catheter without success.
DIAGNOSTIC IMPRESSION:
Probable false passage.
RECOMMENDATIONS:
Since the patient is not uncomfortable, I have recommended 1 of 2 choices. Either he could get admitted and have a suprapubic tube placed or since he is not uncomfortable and not in overt retention, he probably could wait until the morning and follow up with Dr. H***** for placement of a catheter under visual cystoscopy in his office if he decides to do so.
HISTORY OF PRESENT ILLNESS:
The patient is an 85-year-old male with BPH. Apparently, he was seen recently in the emergency room for a catheter placement, which failed. He was seen by Dr. R*** who performed cystoscopy with placement of a catheter. The patient saw his regular urologist, Dr. H*****, today who decided to remove the catheter. He now comes to the ER not having voided in the past 8 hours. He is not uncomfortable. PVR in the ER was 370 mL. Bladder scan in the ER was 370 mL.
PAST MEDICAL HISTORY:
Positive for BPH, coronary artery disease, prior TURP, leukocytosis, overactive bladder, pacemaker, Parkinson's, atrial fibrillation.
REVIEW OF SYSTEMS:
As dictated above.
PHYSICAL EXAMINATION:
GENERAL: He is an afebrile male lying comfortably in bed. No apparent distress.
HEENT: Normal.
LUNGS: Clear.
COR: S1, S2 normal.
ABDOMEN: Benign. No bladder distention.
EXTREMITIES: Normal.
PROCEDURE:
The patient had undergone several prior attempts to pass a catheter by the emergency room staff. I was called to see if I could get it in place. I tried both a 12-French and a 14-French coude catheter without success.
DIAGNOSTIC IMPRESSION:
Probable false passage.
RECOMMENDATIONS:
Since the patient is not uncomfortable, I have recommended 1 of 2 choices. Either he could get admitted and have a suprapubic tube placed or since he is not uncomfortable and not in overt retention, he probably could wait until the morning and follow up with Dr. H***** for placement of a catheter under visual cystoscopy in his office if he decides to do so.