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The use of any urodynamic testing for screening in asymptomatic patients, except for evaluation of neurogenic bladder or urological abnormalitites associated with complex anorectal malformation. These CPT codes represent the most commonly ordered ultrasound exams. Documentation of how PVR is used in medical decision-making can be explicit or implicit in the documentation for the visit and is not required to be documented in the same place as the postvoid amount and reason for PVR. The CPT codes include the following: 51798 Measurement of post-voiding residual urine and/or bladder capacity by ultrasound non-imaging This ultrasound does not use imaging to obtain a post-voiding residual urine. Complex cystometrogram (i.e., calibrated electronic equipment) with voiding pressure studies (i.e., bladder voiding pressure) and urethral. What is Neurogenic Bladder Nemours Children’s Health System Internet. More than one cystometrogram (CPT codes 51725 or 51726) or uroflowmetry study (CPT codes 51736 or 51741) per visit. Documentation should include the reason the postvoid residual (PVR) was obtained that day, the postvoid amount, should indicate that ultrasound was used and how it was used in medical decision-making. 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. We have been requesting that medical assistants scan the printout but would like to know if entering the postvoid residual is enough.Ĭode 51798 reads: Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging.Īs such, the code is not treated the same as other ultrasound codes with regard to documentation requirements. What are the documentation requirements for code 51798? Is documenting the residual amount enough, or do we have to have the printout from the bladder scan? Some of the machines do not have the capability to print out the scan.