Wiki Help! Post void residual done without ultrasound?

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trarut

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Non-urology coder here :) We have a Gyn Onc who has a patient coming in for what they are calling a post-void residual and I can't figure out what code we would use.

Procedure as described to me: We will instill XX cc's fluid into the bladder, have the patient void and measure the output to determine the volume retained in order to determine whether to discontinue the patient's catheter.

There will be no ultrasound or other imaging performed so I have ruled out 51798. Would it be reasonable to use 51736?

I'm completely lost!

Tracy
 
The 2 ways to get the PVR urine volume is either urethral cath or the bladder ultrasound. The procedure that was described to you doesn't state a ultrasound won't be done. For CPT 51798 the explanation I have says that "the software bulit into the scanner calculates the post-void residual urine volume immdeiately and also does calculations for the bladder capacity based on the individual's bladder shape and not on fixed geometric formulas."

51798 is the only code I have ever used for post-void.

I also am a certificated urology coder.
 
Hi, Codergirl93.

Our clinical manager definitely confirmed that we would not be doing an ultrasound and would simply be measuring the output to calculate the retained volume. We will take a look at 51798 again. I realized earlier today that 51736 is not a realistic option for what we're doing so I was hoping someone would respond :)

Thanks for the reply!

Tracy
 
michelleaapc2012 said:
I would use 51798, I have a CPC and work for a urology practice. This is a common procedure for us.
Click to expand...

I agree with michelleaapc2012. The other code you asked about would be a timed one and from the sounds of it a stop watch is used but I could be wrong on that. But 51798 is the most common code used for PVR.
 
So sorry for the delayed response ... I have been having problems getting logged into the forum :(

I appreciate the advice from both of you and have passed it along to my management.

Tracy
 
Wow.....

You were led down the wrong path.... and you should not use 51798 if you are not using a PVR machine. As mentioned previously, the code description states specifically that this is done by ultrasound scanner, and you're not using one so how would this code be appropriate? I'm shocked (and a little embarassed) that several people recommend using this code when the work performed doesn't align with the code description.

I would consider using 51700 since the work performed is just a simple bladder instillation. If your physician were to document an approx. flow rate, then you could bill 51736 for a simple uroflowmetry instead on 51700.

Plain and simple, code only for the services performed and the equipment used.
 
emcee101 said:
You were led down the wrong path.... and you should not use 51798 if you are not using a PVR machine. As mentioned previously, the code description states specifically that this is done by ultrasound scanner, and you're not using one so how would this code be appropriate? I'm shocked (and a little embarassed) that several people recommend using this code when the work performed doesn't align with the code description.

I would consider using 51700 since the work performed is just a simple bladder instillation. If your physician were to document an approx. flow rate, then you could bill 51736 for a simple uroflowmetry instead on 51700.

Plain and simple, code only for the services performed and the equipment used.
Click to expand...

I am a urology coder and we use this code for when they instill saline into the bladder and they do a trial of void to see if they can remove the cath.

Machelle Freeman-CPC
 
51798 used no matter imaging

http://www.auanet.org/practice-reso...rmation/ultrasound-documentation-requirements

AUA webpage states 51798 is used no matter what type of image was obtained OR if an image was obtained at all.





trarut said:
Non-urology coder here :) We have a Gyn Onc who has a patient coming in for what they are calling a post-void residual and I can't figure out what code we would use.

Procedure as described to me: We will instill XX cc's fluid into the bladder, have the patient void and measure the output to determine the volume retained in order to determine whether to discontinue the patient's catheter.

There will be no ultrasound or other imaging performed so I have ruled out 51798. Would it be reasonable to use 51736?

I'm completely lost!

Tracy
Click to expand...
 

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Would you just use 51701 for the bladder cath and an E&M? Seems like that is what this is saying...

Q. How do I bill for urinary bladder catheterizations?
A. There are several codes for this procedure. A brief description of each follows:

CPT® code 51701Insertion of non-indwelling bladder catheter (e.g., straight catheterization for residual urine): This code is used when a non-indwelling bladder catheter is inserted and immediately removed after urine is obtained for diagnostic purposes, i.e., sterile urine specimen (commercial payers only) or a post-voiding residual urine (commercial or Medicare).
 
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