Superb guide for Cpt code for Cystography with sample reports

Cystography is performed to study the lower urinary tract. Cystography helps in evaluating hydronephrosis, hematuria, bladder cancer, vesicoureteral reflux and bladder polyps. Cpt Code for cystography in medical coding is very important. In cystography, physician inserts a catheter in bladder and injects contrast medium to study urinary bladder. The images of the bladder (cystogram) are obtained. Images during filling, voiding and post-voiding are also obtained. The flow of contrast helps in evaluating function of bladder. When the bladder is filled and then emptied we can assess the function of bladder and lower urinary tract. For non-voiding (74430) and voiding (75544) we have different S&I CPT code for Cystography. These tips are really important for Certification exams like CPC, you can go through sample CPC questions here which will surely help in clearing CPC exam
Learn Cpt code for Cystography with sample reports
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CPT code for Cystography
The normal injection procedure for Cystography is coded as 51600. But, when a chain of contrast is used in cystography we use cpt 51605. When the catheter is inserted in urethra and contrast in injected in retrograde direction (against the normal flow of urine) then we code CPT 51610.The detail description about CPT code along with S&I code is given below.
Procedure Description
CPT code
Supervision and Interpretation code (S&I code)
Cystography Injection procedure + X-ray of bladder
51600
74430
Injection procedure + voiding urethrocystography
51600
74455
Urethrocystography Injection procedure with a chain of contrast
51605
74430
Retrograde urethrocystography injection procedure
51610
74450


S & I used with CPT code for cystography

 

74450- A radiologic exam to diagnose stricture, obstruction and/or postoperative function of bladder, performed mostly on males. It is performed with the help of balloon catheter. The balloon catheter is inserted in retrograde direction against the normal flow of urine in the urethra. Balloon is inflated and contrast medium is injected with the help of fluoroscopy. Images are obtained as the contrast flow against the normal flow in retrograde direction through the urethra and into the bladder. The bladder is drained and more images are obtained. This cpt 74450 is coded with main surgical procedure 51610 as supervision and interpretation.
74430- This is a radiographic exam of bladder using contrast material. Minimum three views are taken during this exam. The catheter is inserted directly in the bladder and contrast is injected. Once the bladder is full, it is drained and more images are obtained. This code is used with surgical procedure CPT Code 51600.  Cpt Code 74430 is used as supervision and interpretation for 51600.
74455- This exam is performed when the bladder is fully empty. The catheter is first inserted through the urethra into the bladder and then contrast medium is injected till it fills the bladder under fluoroscopy. Images can be obtained if there is any reflux of contrast medium present. Once voiding commences, catheter is removed and during voiding and post voiding images are obtained. This CPT code is used with surgical procedure cpt 51600. Cpt 74455 is used as supervision and interpretation code for cpt 51600.

Sample Report for CPT code for Cystography and Voiding Urethrocystography


Exam: CT Cystogram
History: Trauma
CT CYSTOGRAM
Clinical Indication: Trauma, hematuria

Procedure: Images through the pelvis were obtained without IV contrast. Contrast material was instilled into the bladder via a Foley catheter.
Findings: Contrast material nearly completely distends the bladder. The bladder wall is intact without extra luminal extravasation identified. Foley catheter with inflated balloon terminates within the bladder lumen. The prostate and seminal vesicles are unremarkable. No pelvic free fluid or lymphadenopathy identified. Included loops of bowel are normal in course and caliber. No acute osseous abnormality identified. Scattered sub centimeter sclerotic foci within the left acetabular roof and left femoral head are most in keeping with benign bone islands in the absence of known malignancy.

Impression: Normal CT cystogram. Specifically, the bladder wall is intact without extra luminal contrast extravasation identified.
CPT: 51600, 74430
ICD: 599.70

VOIDING CYSTOURETHROGRAM:
Indication: Multiple UTIs. Small left kidney on prior ultrasound with mild left hydronephrosis.

Technique: A catheter was placed with its tip in the bladder using sterile technique. 400 mL Cystografin was instilled into the urinary bladder. Examination was performed by the fluoroscopy technician under
radiologist supervision.

Findings: Early filling of the urinary bladder showed no abnormal filling defect. The urinary bladder is adequately distended. The urinary bladder demonstrates a normal contour. There is left-sided  vesicoureteral reflux into a dilated left ureter and collecting system with blunting of the calyces.
No right-sided reflux is noted. There is a moderate amount of post void residual within the urinary
bladder.
Fluoroscopy: 0.9 minutes of fluoroscopy time was used.
Impression:
1. Left-sided grade 4 vesicoureteral reflux.

CPT: 51600, 74455-26
ICD: 599.0, 591
Hope, now you can code CPT code for Cystography easily after reading this short guide.

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