Sonnia Posted Thu 01st of February, 2018 11:09:12 AM
There's a lot of bundled codes and want to make sure I don't miss out on proper coding. Op note: Scope inserted sterilely through the native urethra with the aforementioned findings. Bladder inspected in systematic fashion. A specimen was sent for culture. Right-sided stent was seen emanating through ureteral orifice. It was grasped and removed without difficulty. Guidewire placed to the stent and advanced up to the renal pelvis with fluoroscopic guidance. Over the guidewire, a dual-lumen catheter was placed and a 2nd guidewire was placed. Ureteroscopy was then performed which demonstrated no stricture of the entire ureter. Retrograde pyelography was also performed which demonstrated dilated ureter. There was no UPJ and there was no UVJ with ureteroscopy. Ureteroscopy was advanced over the guidewire and the entire ureter was evaluated on its way down. The guidewires were then removed, and fluoroscopic images showed that the kidney drained. The kidney insertion to the ureter shows it was high on the bladder. The bladder was very trabeculated. The left side reflux with the cystogram noted in the reflux and the right side still would drain with time. the bladder was then drained, refilled after endoscopy was performed and the SP tube replaced under visualization. The curl deployed in the bladder and it was secured in position and placed to drainage utilizing the Dawson Mueller. The patient was awakened, transferred to the recovery room stabled. Codes charged are 52000, 52351, 52005, 52310, 51710, & 51610 but would have to remove 52000, 52005, 52310 due to bundling. I have a question about 51610 my understanding is this code can only be used if performed via a catheter not scope. Is this correct?
SuperCoder Answered Fri 02nd of February, 2018 08:48:21 AM
As per the detailed discription of CPT 51610, contrast material is injected through urethral catheter or catheter-tipped syringe. But documentation above does not say injection throught scope. However, retrograde pyelography was performed which demonstrated dilated ureter. Also, 51610 shows bundling with 52005 and 52000. Please feel free to ask for any further query.
Sonnia Posted Fri 16th of February, 2018 10:30:30 AM
To clarify, 51610 is to be used for contrast material injected via a urethral catheter or catheter-tipped syringe and if it's through a scope then use 52005?
SuperCoder Answered Tue 20th of February, 2018 09:51:22 AM
Not only scope but there are other Criteria’s as well mentioned below to use these codes.
51610 is to be used for contrast material injected via a urethral catheter or catheter-tipped syringe plus X-rays are taken. Filling, voiding and post voiding x-rays are obtained which will be included in this code. However, in cpt 52005 contrast is injected throught catheter throught cystourethroscope for radiology study but radiology services will not be covered in this code. Hope it helps.