How To Use CPT Code 51798

CPT 51798 is an ultrasound procedure used to measure the volume of residual urine in the bladder and/or bladder capacity. This article will cover the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 51798 procedures.

1. What is CPT 51798?

CPT 51798 is a medical procedure code used to describe the measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging. This procedure is performed to assess the volume of urine left in the bladder after the patient has voided, which can help diagnose urinary retention and other bladder-related issues.

2. 51798 CPT code description

The official description of CPT code 51798 is: “Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging.”

3. Procedure

The 51798 procedure involves the following steps:

1. The patient is asked to urinate to void the bladder before the exam.
2. The patient is placed in the supine position.
3. Ultrasound gel is applied to the lower abdomen.
4. The ultrasound probe (transducer) is placed on the skin’s surface.
5. The transducer emits sound waves through the skin, which return back to the transducer as echoes.
6. The transducer converts the returning echoes into electrical signals to calculate the volume of urine left in the bladder.

4. Qualifying circumstances

Patients who are eligible to receive CPT code 51798 services include those experiencing symptoms of urinary retention, such as difficulty urinating, weak urine flow, or frequent urination. This procedure may also be performed on patients with a history of urinary tract infections, bladder dysfunction, or other related conditions. A healthcare provider may recommend this test to evaluate the effectiveness of treatments for these conditions or to monitor the patient’s progress over time.

5. When to use CPT code 51798

It is appropriate to bill the 51798 CPT code when the purpose of the ultrasound is to measure the volume of residual urine in the bladder and/or bladder capacity. This code should be used when the provider performs the procedure using a portable ultrasound scanner over the supra-pubic area to measure the residual urine. The scanner’s built-in software will record the post-void residual urine volume and provide the bladder’s capacity based on the patient’s actual bladder shape.

6. Documentation requirements

To support a claim for CPT 51798, the following information should be documented:

• Patient’s medical history and symptoms related to urinary retention or bladder dysfunction.
• Physical examination findings, including any abnormalities in the lower abdomen or urinary system.
• Details of the ultrasound procedure, including the patient’s position, application of ultrasound gel, and placement of the transducer.
• Results of the post-void residual urine measurement and/or bladder capacity calculation.
• Any additional findings or observations made during the procedure.
• Provider’s interpretation of the results and any recommendations for further evaluation or treatment.

7. Billing guidelines

When billing for CPT code 51798, keep in mind the following guidelines and rules:

• A separate E/M visit can be billed on the same day as the ultrasound, but a 25 modifier may be required.
• Carriers closely scrutinize separate E/Ms billed with 51798, so ensure there is a separate diagnostic reason for an E/M visit.
• Since 51798 has no separate professional or technical component, it cannot be billed only for professional services.
• There is no interpretation involved in 51798, as it is only a measurement. Interpretation can be billed if the provider interprets a pelvic or bladder and kidney ultrasound.

8. Historical information

CPT 51798 was added to the Current Procedural Terminology system on January 1, 2003. There have been no updates to the code since its addition.

9. Similar codes to CPT 51798

Five similar codes to CPT 51798 and how they differentiate from CPT 51798 are:

• CPT 51741: This code is used for an electromyography study of the urethral sphincter, which assesses the function of the muscles controlling urine flow.
• CPT 76770: This code describes a complete ultrasound examination of the urinary tract, including the kidneys, bladder, and surrounding structures.
• CPT 76775: This code is for a limited or follow-up ultrasound examination of the urinary tract, focusing on specific areas of concern.
• CPT 76856: This code is used for a complete ultrasound examination of the female pelvic organs, including the uterus, ovaries, and fallopian tubes.
• CPT 76857: This code describes a limited or follow-up ultrasound examination of the female pelvic organs, focusing on specific areas of concern.

10. Examples

Here are 10 detailed examples of CPT code 51798 procedures:

1. A patient with a history of urinary tract infections presents with difficulty urinating and a weak urine flow. The provider performs CPT 51798 to assess the post-void residual urine volume.
2. A patient with a known bladder dysfunction undergoes CPT 51798 to monitor their bladder capacity over time.
3. A patient experiencing frequent urination and discomfort in the lower abdomen undergoes CPT 51798 to evaluate the volume of residual urine in their bladder.
4. A patient with a history of urinary retention undergoes CPT 51798 to assess the effectiveness of a new treatment regimen.
5. A patient with a neurogenic bladder undergoes CPT 51798 to evaluate their bladder capacity and post-void residual urine volume.
6. A patient with a history of prostate enlargement undergoes CPT 51798 to assess the impact of the condition on their bladder function.
7. A patient with a spinal cord injury undergoes CPT 51798 to evaluate their bladder capacity and residual urine volume.
8. A patient with a history of pelvic surgery undergoes CPT 51798 to assess the impact of the surgery on their bladder function.
9. A patient with a known bladder diverticulum undergoes CPT 51798 to evaluate the volume of residual urine in their bladder.
10. A patient with a history of recurrent kidney stones undergoes CPT 51798 to assess their bladder capacity and post-void residual urine volume.