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How do you bill for a post-void residual performed without ultrasound?

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“If one performs a bladder catheterization to obtain the post-void residual, use CPT code 51701,” write Jonathan Rubenstein, MD, and Mark Painter.

I read your post titled, “What are the documentation requirements for code 51798?1 It was very helpful. I would also like to know which Common Procedural Terminology (CPT) code we would use for a post-void residual done without ultrasound.

Jonathan Rubenstein, MD

Jonathan Rubenstein, MD

To best answer your question, we would need to know a bit more specifically what is meant by “without ultrasound.” Do you mean by catheter, or do you mean a hand-held device that detects the bladder volume? CPT code 51798’s description reads, “Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging.” Therefore, whether the bladder is actually imaged, and the volume calculated or a non-imaging device is used to give a bladder volume, the code can be used. If one performs a bladder catheterization to obtain the post-void residual, use CPT code 51701 (Insertion of non-indwelling bladder catheter [eg, straight catheterization for residual urine]).

Mark Painter

Mark Painter

Can CPT 52601 be coded more than once per patient?

CPT code 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included])still has a “once in a lifetime” restriction. If a subsequent transurethral resection of the prostate is performed, use CPT code 52630 (Transurethral resection; residual or regrowth of obstructive prostate tissue including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]).

Reference

1. Painter R, Painter M. What are the documentation requirements for code 51798? Urology Times®. August 14, 2019. Accessed January 12, 2021. http://bit.ly/2XwBaMe.

Send coding and reimbursement questions to Rubenstein and Painter c/o Urology Times®, at urology_times@mmhgroup.com.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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