Complications in Urinary Retention Coding

When you talk about urinary retention, office visit and the placement of a Foley catheter—modifier -76 and -59 will definitely come in conversation. Suppose on day one the patient presents as a new patient to the urologist in urinary retention. The urologist examines the patient, takes their history and realizes the patient is in urinary retention and also places a Foley catheter, a 51702. You would bill the 99204 with modifier -25 and the Foley catheter insertion, a 51702. Patient goes home and during the night, the catheter falls out. He presents to the urologist the second day or day two in the morning and again in urinary retention. The urologist examines the patients, re-determines that he's in urinary retention and places another Foley. You should bill the office visit 99212 with modifier -25 to ensure payment of the E/M service. And you can also bill for another catheter the following day, 51702 because the 51702 has a zero day global, meaning that anything you do after the next day after you placed the catheter is a billable service.

Let's change that a bit and let's say on day one in the morning, the same thing happens, the urologist determines the patient is in urinary retention and puts a Foley catheter. Now the patient goes home, in that early afternoon, the catheter falls out. And later that same day, day one, he goes back to the urologist who determines again that he is in urinary retention. Most carriers will not pay a second E/M service on the same day especially if that service is related to the same problem, urinary retention. However, you should bill and you will be paid for the insertion of a second catheter on that same day, 51702, when you use modifier -76. Now, modifier -76 says, “The same urologist for the same individual patient did the same procedure for the same reason on the same day.” In other words, he put in the catheter again in the same patient, same day, same reason, urinary retention, adding modifier -76.  There are some carriers that will not pay for modifier -76. And if that is the case, change modifier -76 to -59 and expect to be paid for that second Foley insertion.

When we catheterize a patient and then irrigate out the Foley for reasons of bleeding or clot retention, you would want to bill a 51701 or a 51702 for the catheterization. And you would want to bill a 51700 for the irrigation. However, the 51701 and the 51702 are bundled into the irrigation code. These edits cannot be bypassed with any modifier. In other words, you can only bill one of those CPT codes. Now remember that the relative value units or payment for the irrigation is more than the relative value units in the payment for the insertion of a foley or for the simple insertion and removal of a catheter.

So under these circumstances when you put in a catheter and irrigate the bladder most often for removal of clots, you should bill only the CPT code 51700. And this pertains to the whether the service is provided in the office or the hospital. Now, the irrigation code 51700 is also bundled into the 51703. That's the complicated Foley catheter insertion. Remember that this edit cannot be bypassed with any modifier so you have to bill either the 51700 or the 51703. The relative value units or a payment for the 51703 pays more than the relative value units or payment for the irrigation codes. So, you should only bill the CPT code 51703 when this clinical scenario happens either in the office or the hospital.

Now your diagnosis, if it is latter code using the 51703, is urethral stricture, the primary diagnosis 598.9, the clot retention as a secondary diagnosis 596.8 and gross hematuria 599.71. Now, when you're billing the irrigation code as in the above example, you can use clot retention, 596.8 or the code for gross hematuria, 599.71.