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Official Description

Injection procedure for cystography or voiding urethrocystography

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 51600 refers to an injection procedure specifically designed for cystography or voiding urethrocystography. This procedure involves the instillation of contrast media into the bladder, utilizing a method that is distinct from the traditional retrograde injection technique. For instance, in cases where a patient has a suprapubic catheter in place, the contrast media is introduced through this existing catheter rather than through the urethra. The primary purpose of this procedure is to visualize the bladder and urethra during imaging studies. In cystography, radiographs are taken of the bladder as it is progressively filled with the contrast agent, allowing for the identification of any abnormalities in the bladder's filling pattern. Conversely, during voiding cystourethrography, radiographs are captured both while the bladder is being filled and as it is being emptied, providing a comprehensive view of the bladder and urethra's function and structure. This procedure is essential for diagnosing various urological conditions and assessing the anatomy and function of the urinary tract.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The injection procedure for cystography or voiding urethrocystography is indicated for various clinical scenarios where visualization of the bladder and urethra is necessary. The following conditions may warrant this procedure:

  • Evaluation of Bladder Abnormalities This procedure is performed to assess any abnormalities in the bladder's structure or function, such as tumors, diverticula, or other lesions.
  • Assessment of Urinary Tract Obstruction It is indicated when there is a suspicion of obstruction within the urinary tract that may affect bladder function.
  • Investigation of Urinary Incontinence The procedure helps in diagnosing the underlying causes of urinary incontinence by visualizing the bladder and urethra during filling and voiding.
  • Post-Surgical Evaluation Following surgical interventions involving the bladder or urethra, this procedure can be used to evaluate the surgical site for complications or healing.

2. Procedure

The injection procedure for cystography or voiding urethrocystography involves several key steps to ensure accurate imaging and assessment of the urinary tract. Each step is crucial for the successful completion of the procedure.

  • Step 1: Preparation of the Patient The patient is positioned appropriately, and the area around the suprapubic catheter or the intended injection site is cleaned and sterilized to minimize the risk of infection. The healthcare provider explains the procedure to the patient, ensuring they understand the process and any potential discomfort.
  • Step 2: Instillation of Contrast Media Using a sterile technique, contrast media is injected into the bladder through the suprapubic catheter or another access point. The volume and type of contrast used are determined based on the specific requirements of the imaging study.
  • Step 3: Radiographic Imaging As the bladder fills with contrast, radiographs are taken to capture images of the bladder's shape and any filling abnormalities. For voiding cystourethrography, additional images are obtained as the patient voids, allowing for visualization of the urethra and bladder during the emptying process.
  • Step 4: Evaluation of Images The radiographs are reviewed by a qualified radiologist or physician, who assesses the images for any abnormalities or issues that may require further investigation or intervention.

3. Post-Procedure

After the injection procedure for cystography or voiding urethrocystography, the patient may be monitored for a short period to ensure there are no immediate adverse reactions to the contrast media. It is important to provide the patient with instructions regarding hydration to help flush the contrast from their system. Additionally, the patient should be informed about any potential side effects, such as mild discomfort or urinary urgency, which may occur following the procedure. Follow-up appointments may be scheduled to discuss the results of the imaging studies and any necessary further evaluations or treatments based on the findings.

Short Descr INJECTION FOR BLADDER X-RAY
Medium Descr NJX CSTOGRAPY/VOIDING URETHROCSTOGRAPY
Long Descr Injection procedure for cystography or voiding urethrocystography
Status Code Active Code
Global Days 000 - Endoscopic or Minor Procedure
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Items and Services Packaged into APC Rates
ASC Payment Indicator Packaged service/item; no separate payment made.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) I1F - Standard imaging - other
MUE 1
CCS Clinical Classification 200 - Nonoperative urinary system measurements
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
GC This service has been performed in part by a resident under the direction of a teaching physician
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
X5 Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CR Catastrophe/disaster related
GA Waiver of liability statement issued as required by payer policy, individual case
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
LT Left side (used to identify procedures performed on the left side of the body)
MC Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues
MG The order for this service does not have applicable appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional
PD Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
QQ Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was provided to the furnishing professional
RT Right side (used to identify procedures performed on the right side of the body)
SG Ambulatory surgical center (asc) facility service
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
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