Basic about urethral catheterization CPT code

Urinary catheters are used when patient is unable to empty his or her bladder. If the urine is retained in bladder, pressure is developed in the kidney. Such pressure can lead to harmful disorder like kidney failure. The urinary catheter has a tiny balloon attached at the end. When the catheter is placed in bladder, the balloon is inflated and it helps to keep it stable and immobile. When to remove the urinary the catheter balloon is deflated and the catheter is removed. Urethral catheterization CPT Code 51701, 51702 & 51703 are used in surgery facility for coding. In medical coding, urethral catheterization procedure is used very commonly coded. The urethral catheterization CPT codes are few but are little tricky to code. Before placing urinary catheter the physician can perform renal ultrasound doppler exam or a nephrostogram procedure for finding any obstruction in the urinary tract.

Read also: CPT codes for Coding Stent and Angioplasty Procedures

Documentation for urethral catheterization CPT Code

Patient with residual urine problem are treated with urethral catheterization procedure. The urethral catheterization cpt code includes use of non-dwelling and indwelling catheter. The indwelling catheter like Foley catheter stays or allowed to remain in the bladder. Common indications for urethral catheterization CPT Code include acute or chronic urinary retention, which can be harmful for kidneys. Hence, urethral catheterization procedure is performed. Let check each of urethral catheterization CPT Code.

A non-indwelling catheter is inserted into the bladder. This may be referred to as straight catheterization. Straight catheterization is performed to empty the bladder of urine or to test for residual urine following urination, which indicates incomplete emptying of the bladder. If the patient is being checked for residual urine, the patient first empties the bladder into a container and the amount is measured. A catheter kit is prepared. The urethra is cleansed with antiseptic solution. A sterile catheter is then inserted through the urethra into the bladder. Urine is drained from the bladder and the amount of residual urine is measured.

51701- Insertion for non-indwelling bladder catheter ((eg, straight catheterization for residual urine)

This procedure is performed when we have to removal directly the residual urine after placing the catheter. In this procedure, the non-indwelling catheter is used. These catheters are placed straight away in the bladder to remove the residual urine.

A temporary indwelling catheter is inserted into the bladder. This may be referred to as Foley catheterization. A catheter kit is prepared. The urethra is cleansed with antiseptic solution. A sterile Foley catheter is inserted through the urethra into the bladder. The balloon is then inflated with about 10 cc of water to keep it in place. The catheter is attached to a sterile drainage bag and urine is continuously drained from the bladder. CPT code 51702  is reported for a simple catheterization procedure and CPT code 51703 for a procedure complicated by altered anatomy or a fractured catheter or balloon.

51702- Insertion of temporary indwelling bladder catheter: simple

51703- Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon)

This code is reported when the physician has any difficulty placing the bladder catheter. The urologist should only place the catheter then only this code should be reported. Do not code this report if the Nurse places it. Also, ensure the documentation clearly documents the difficulty in placing the catheter in bladder by the physician.

Do not report 51702 in conjunction with 0071T, 0072T

Read also: How to Clear CPC exam in First Attempt

Additional Code Information for Urethral catheterization CPT Code 51701, 51702 & 51703

PC/TC Indicator (26):0 = Physician Service Codes
Multiple Procedures (51):2 = Standard payment adjustment rules for multiple procedures apply
Bilateral Surgery (50):0 = 150% payment adjustment for bilateral procedures does not apply
Physician Supervision:09 = Concept does not apply
Assistant Surgeon (80,82):1 = Statutory payment restriction for assistants at surgery applies to this procedure
Co-Surgeons (62):0 = Co-surgeons not permitted for this procedure
Team Surgery (66):0 = Team surgeons not permitted for this procedure
Diagnostic Imaging Family:99 = Concept does not apply

Read also : Coding guide for Parathyroid Imaging CPT codes

RVUs and Fees for CPT code 51701

RVUs and Fees for CPT code 51702

RVUs and Fees for CPT code 51703

Diagnosis Related to urethral catheterization CPT Code

The main diagnosis, which we come across while reporting CPT code 51703 are urethral stricture, false passage and bladder neck contracture. CPT code CPT 51703 even if physician has problem in removing urethral catheter.

ICD -9 codes

598.9 –urethral stricture

599.71- Gross hematuria

599.4- Urethral False passage

596.0- Bladder neck obstruction

ICD -10 codes

N35.9- Urethral Stricture

R31.0- Gross hematuria

N36.5- Urethral False passage

N32.0- Bladder neck obstruction

Hope, now you can code urethral catheterization CPT Code easily with correct diagnosis.