cpt 51798, cpt code 51798, 51798 cpt code

CPT Code 51798 | Description, Procedure & Billing Guidelines

CPT 51798 can measure the amount of urine left in a patient’s bladder (post-voiding residual urine) with ultrasound. 

1. What Is CPT Code 51798?

CPT 51798 covers an ultrasound procedure for measuring how much residual urine is left in a patient’s bladder.

2. Description

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

3. Procedure

The 51798 CPT code procedure starts with the provider asking the patient to urinate, so the bladder is empty.

Then, the provider starts by assessing the amount of urine left in the bladder (also called post-void residual (PVR)).

The provider starts by placing the patient in the supine position. Then, they apply ultrasound gel on the patient’s lower abdomen.

They then place the transducer on the patient’s skin to transmit sound waves through the skin. Finally, the transducer converts the echo of the sound waves into electrical signals.

The provider can read these results and show how much urine is left in the patient’s bladder.

4. Billing Guidelines

CPT code 51798 does not have a technical or professional component. Therefore, do not bill the professional component alone.

This procedure only involves a measurement. Therefore, no interpretation is applied. However, you may report interpretation for bladder and kidney or a pelvic ultrasound.

Report CPT code 51798 if the purpose of the ultrasound scan was to measure post-void residual urine.

This code is mostly used for urologists measuring the residual urine with a portable ultrasound scanner. These types of scanners print out the tape and need to be part of the permanent medical record.

The tape is proof of the service and can justify the medical necessity of catheterization. This procedure needs to be documented the results of this test if the tape is not printed.

A portable scanner records post-void residual urine volume in a patient’s bladder and shows the bladder’s capacity based on its shape. The patient might be catheterized if a lot of urine was detected in the bladder because this indicates retention.

Make sure to report catheterization as a separate procedure.

4.1 Does CPT Code 51798 Need A Modifier?

Use modifier 25 in combination with CPT code 51798 if you bill a separate E/M service on the same day. Do not bill a separate E/M visit if there is no diagnostic reason.

5. Resources

CPT Professional 2022

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=57050&ver=6&=

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=34085&ver=14

https://www.aapc.com/codes/coding-newsletters/my-urology-coding-alert/reader-question-report-51798-for-ultrasound-to-check-bladder-volume-156256-article

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