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Diagnostic studies of the bladder and urethra are frequently ordered to detect anatomic or functional abnormalities of the lower urinary tract. Cystography is performed when the ordering physician wants to examine the bladder, which collects and stores urine after the kidneys have processed it. Different types of urethrocystography may be performed when conditions involving the urethra, the tube leading from the bladder to the outside of the body, are also suspected. Besides the imaging, radiologists may also report a variety of contrast injection procedures, if they performed these services. Coding Studies of the Bladder Cystography allows the radiologist to view the bladder \" explains Patti Offner RT with Diagnostic Imaging Inc. in Philadelphia. \"The bladder is emptied immediately before the procedure and a catheter is inserted through the urethra into the bladder. Once the catheter is in place the radiologist will fill the bladder with contrast material.\" During a typical session abdominal x-rays will be taken before and while the bladder is filling with contrast. Voiding and postvoiding radiography images may also be obtained. According to Chris Sari CPC RCC quality assurance manager for Advanced Radiology in Baltimore fluoroscopy may be used with standard x-rays. The imaging portion of the procedure is reported with 74430 (cystography minimum of three views radiological supervision and interpretation) Offner says with the radiologist obtaining multiple images. \"This may occur for a number of reasons. Because of the patient's condition it may take time for the bladder to fill properly or it may take time for the patient to void the bladder. And the radiologist usually wants films after the bladder has completely emptied because the residual volume may provide valuable information.\" No matter how many images are obtained 74430 is reported only once. Delayed films are considered part of the overall study and may not be reported separately. Along with the imaging code radiologists who perform the injection of contrast media may also report that service with one of two codes: 51600* (injection procedure for cystography or voiding urethrocystography) or the rarely used 51605 (injection procedure and placement of chain for contrast and/or chain urethrocystography). Code 51600 * is a starred procedure which means services include only the surgical procedure. Routine follow-up care is not part of a global package and may be reported separately. One common error plagues coders when reporting cystography -- they also attempt to report the catheter-ization (e.g. 53670 catheterization urethra; simple). However catheterization is part of the surgical codes (51600 and 51605) and should not be reported separately. In fact if a catheter is already in place and that work is not done during the cystography modifier -52 (reduced services) should be appended to the surgical code. Among the ICD-9 codes for cystography are 596.0 (bladder neck obstruction acquired) 596.2 (vesical fistula not elsewhere classified) 596.3 (diverticulum of bladder) 599.0 (urinary tract infection site not specified) 753.6 (atresia and stenosis of urethra and bladder neck congenital) and 788.31 (urge incontinence). Retrograde or Voiding Studies May Be Included Two codes describe imaging of the urethra -- 74450 (urethrocystography retrograde radiological supervision and interpretation) and 74455 (urethrocystography voiding radiological supervision and interpretation). As with cystography both x-rays and fluoroscopy are performed with these exams. According to Sari the difference between these studies is straightforward. Retrograde (74450) indicates the study is done against the normal flow of urine with contrast injected so the urethra is visualized from the injection-of-contrast site back to the urinary bladder. It is always performed on male patients. Retrograde urethrocystography involves the insertion of a catheter into the urethral opening but not into the bladder. Contrast is injected through the catheter into the urethra and followed as it flows retrograde into the bladder. The radiologist looks for the presence of abnormalities in the urethra and the bladder as well as any passive reflux of contrast flowing backward into the ureter which connects the kidneys with the bladder. Voiding urethrocystography (74455) on the other hand provides images of the flow of contrast (and therefore urine) leaving the bladder through the urethra and exiting the body. First the radiologist also looks for abnormalities in the bladder and passive reflux into the ureters as the bladder is filled with contrast. The contrast is instilled through an indwelling catheter placed in the urethra. During voiding the radiologist also evaluates the urethra but in an antegrade (with the flow) rather than retrograde fashion. The radiologist also evaluates for active reflux into the ureters during voiding. \"Video fluoroscopy is often used during a voiding study to provide better images of the flow \" Sari adds. Injection code 51610 (injection procedure for retrograde urethrocystography) is reported with 74450 while 51600 is used with 74455. As with the cystography code catheterization should not be billed in addition to the injection and imaging services. Among the ICD-9 codes that could be assigned with 74450 and 74455 are 753.6 867.0 (injury to pelvic organs; bladder and urethra without mention of open wound into cavity) 598.xx (urethral stricture) and 599.6 (urinary obstruction unspecified). Sometimes a urologist or other specialist performs the injection and obtains the images but asks the radiologist to interpret the findings. When this occurs the radiologist should report only the radiology code (74430 74450 or 74455) with modifier -52 (reduced services). This indicates that the radiologist did not supervise the study but provided only interpretation of the films. Also if the imaging is conducted in a hospital setting the radiologist should append modifier -26 (professional component) to the radiology codes. Medicare code G0050 (measurement of post-voidal residual urine and/or bladder capacity by ultrasound) may be reported when this service is provided after the previous studies are performed. "
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