Cindy Posted Tue 30th of April, 2019 12:30:03 PM
My physician performed the following procedure in the office. This is post op from another physician who actually did the surgery. Patient is here today for a voiding trail post uterine prolapse repair 2/16/19. A UA was collected per instruction from Dr. Baker. The bladder was then filled with 300 mL of NS by gravity. Order originally called for sterile water however, this was not in stock. NS was used . Pt denied any increased discomfort after NS was infused into bladder. Foley catheter was then removed. Pt had an immediate sensation to void. She was unable to void after 10 minutes. Pt was instructed on proper technique for self catheterization. I cannot find a good cpt code for this. There is one that uses an ultrasound, but this was not the case. Is there a cpt code for this procedure or do you just bill an office call? thank you
SuperCoder Answered Wed 01st of May, 2019 07:36:03 AM
Thanks for your question.
As per limited information, we are providing the different scenarios for you to select from:
First of all, please make sure if this is under postoperative period of the original surgery (i.e. uterine prolapse repair). When reported during the follow-up period of a surgery, the appropriate surgery modifier (78, 79, 58 [staged or related procedure or service by the same physician during the postoperative period] etc.) may be reported.
In the case of a female patient who presents with a complaint that she doesn't feel as if she empties her bladder completely when she voids, the physician will insert a catheter to drain her bladder and measure the amount of urine drained to determine how much urine she is retaining. If this is the case, report the insertion with CPT® code 51701.
If the patient presents in acute urinary retention, the physician will insert a temporary indwelling Foley catheter, and the patient will leave with the catheter in place. If this is the case, report this with CPT® code 51702.
Now, if this is a simple cystometrogram, i.e. if the physician places a small catheter in the bladder, and fills the bladder using gravity to measure the capacity and storage pressures using a spinal manometer, then code 51725 can be reported.
The cystometrogram indicates if the detrusor muscle is functioning properly and detects the capacity of the bladder and any abnormal detrusor sphincter contractions. If the patient's incontinence is due to stress, the cystometrogram will appear normal.
Code 51725 describes a simple CMG that uses a spinal manometer to measure bladder pressures at various levels of bladder fullness. Note that if your provider uses electronic equipment for these measurements that would be represented by 51726, Complex cystometrogram [i.e., calibrated electronic equipment].
Please feel free to write if you have any question.
Cindy Posted Wed 01st of May, 2019 07:58:11 AM
Thank you, but you did not answer my question or read my question, as noted, the surgery was done by another physician. As noted no equipment was used, as noted it was not because of urinary retention. As noted this is not limited information, this is the procedure done in the office, it is called a voiding trial, it appears I have misspelled, my apology. Wouldn't procedure cpt 51700 be appropriate. I would not have asked if I wasn't sure, I can look up the cpt codes you listed above, but as mentioned there wasn't any equipment involved. Please if you don't know this answer, find someone who can help me.
SuperCoder Answered Thu 02nd of May, 2019 08:39:40 AM
Thanks for your response. We apologize for any inconvenience caused to you.
In the previous answer, we provided different scenarios because urologists perform a voiding trial in several ways. The codes may be chosen based on the procedures performed by a urologist during the voiding trial.
Voiding trials are common practice for urologists. Physicians often have patients come back to the office for a voiding trial to determine if the patient is able to void after catheter removal. Medicare usually does not pay for postoperative voiding trials following procedures.
However, when a urologist documents that he performed a voiding trial, you will most often be dealing with either a simple bladder irrigation/instillation, or a bladder scan, or both. Here the physician has performed only simple bladder irrigation/instillation. So, code 51700 should be billed for the simple bladder fill.
Hope this helps.