How To Use CPT Code 51100

CPT 51100 describes the procedure of bladder aspiration, which involves the collection of a urine sample or providing temporary relief from acute urinary retention. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 51100?

CPT 51100 is used to describe the percutaneous aspiration of the bladder using a needle. This procedure is performed to collect a urine sample or provide temporary relief from acute urinary retention. It is a fast, simple, and easy-to-perform process.

2. Official Description

The official description of CPT code 51100 is: ‘Aspiration of bladder; by needle.’

3. Procedure

1. The physician applies local anesthesia to the patient.
2. Using ultrasonography, the physician locates the bladder.
3. A 22-gauge needle with a 10 or 20 mL syringe attached is inserted percutaneously into the bladder region.
4. The physician advances the needle until urine appears within the syringe.
5. If insertion is unsuccessful, the physician adjusts the needle’s direction without completely withdrawing it.
6. After obtaining the urine sample, the physician carefully removes the needle and applies gentle pressure to the insertion site.
7. A sterile dressing is placed on the site.

4. Qualifying circumstances

CPT 51100 is performed when there is a need to collect a urine sample or provide temporary relief from acute urinary retention. It is typically done under the care of a physician and requires the use of a needle for bladder aspiration.

5. When to use CPT code 51100

CPT code 51100 should be used when performing percutaneous bladder aspiration using a needle. It is appropriate for procedures involving the collection of a urine sample or providing temporary relief from acute urinary retention.

6. Documentation requirements

To support a claim for CPT 51100, the physician must document the following information:

• Patient’s condition necessitating bladder aspiration
• Use of local anesthesia
• Date and time of the procedure
• Details of the procedure, including the use of ultrasonography and the size of the needle and syringe
• Amount of urine collected, if applicable
• Any additional procedures performed, such as sending the urine sample for analysis
• Physician’s signature

7. Billing guidelines

When billing for CPT 51100, ensure that the procedure involves percutaneous bladder aspiration using a needle. It is important to follow the appropriate coding guidelines and documentation requirements. CPT code 51100 should not be reported with other codes for bladder aspiration using a trocar or intracatheter. Additional tips for accurate reporting can be found in the official coding guidelines.

8. Historical information

CPT 51100 was added to the Current Procedural Terminology system on January 1, 2008. There have been no updates or changes to the code since its addition.

9. Examples

1. A physician performing bladder aspiration to collect a urine sample for urinalysis.
2. A urologist using CPT 51100 to provide temporary relief from acute urinary retention in a patient.
3. A nephrologist performing bladder aspiration to obtain a urine sample for culture and sensitivity testing.
4. An emergency room physician using CPT 51100 to relieve acute urinary retention in a patient before further evaluation.
5. A primary care physician performing bladder aspiration to collect a urine sample for pregnancy testing.
6. A urogynecologist using CPT 51100 to provide temporary relief from acute urinary retention in a postoperative patient.
7. A pediatrician performing bladder aspiration to collect a urine sample for a child with suspected urinary tract infection.
8. A urologist using CPT 51100 to provide temporary relief from acute urinary retention in a patient with an enlarged prostate.
9. An oncologist performing bladder aspiration to collect a urine sample for cytology testing in a patient with suspected bladder cancer.
10. A geriatrician using CPT 51100 to provide temporary relief from acute urinary retention in an elderly patient with urinary incontinence.