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Official Description

Urethrocystography, retrograde, radiological supervision and interpretation

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Urethrocystography, retrograde, is a radiological procedure that involves the examination of the urethra and bladder using fluoroscopy and a radiopaque contrast medium. This procedure is essential for diagnosing various conditions affecting the urinary tract, including injuries, congenital anomalies, tumors, diverticula, stones, fistulas, strictures, and obstructions. During the procedure, the contrast medium is carefully instilled through the external urethral orifice, which allows for the distension and filling of both the urethra and bladder. This process is crucial as it enhances the visibility of these structures on X-ray images. The radiological supervision provided during this procedure ensures that the imaging is conducted accurately and safely, allowing for the capture of X-rays from one or more angles to obtain a comprehensive view of the urethra and bladder. After the initial imaging, the patient is permitted to void, and an additional X-ray is taken post-voiding to confirm that all contrast has been expelled from the urinary tract. The CPT® Code 74450 specifically reports the radiological supervision and interpretation of the urethrocystography procedure, which includes a thorough review of the obtained records and the generation of a written report detailing the findings.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

Urethrocystography, retrograde, is indicated for a variety of clinical conditions that may affect the urethra and bladder. The following are the specific indications for performing this procedure:

  • Injury - Assessment of potential damage to the urethra or bladder due to trauma.
  • Congenital anomalies - Evaluation of structural abnormalities present at birth that may affect urinary function.
  • Tumors - Identification and characterization of neoplastic growths within the urinary tract.
  • Diverticula - Detection of abnormal pouches that may form in the bladder wall.
  • Stones - Visualization of calculi that may obstruct the urinary tract.
  • Fistulas - Investigation of abnormal connections between the urinary tract and other structures.
  • Strictures - Assessment of narrowing in the urethra that may impede urine flow.
  • Obstruction - Evaluation of blockages that may affect urinary drainage.

2. Procedure

The urethrocystography, retrograde procedure involves several key steps to ensure accurate imaging and diagnosis. The following outlines the procedural steps:

  • Step 1: Preparation - The patient is positioned appropriately, and the area around the external urethral orifice is cleaned to minimize the risk of infection. The healthcare provider explains the procedure to the patient, ensuring they understand the process and any sensations they may experience.
  • Step 2: Contrast Medium Instillation - A radiopaque contrast medium is carefully instilled through the external urethral orifice. This step is crucial as it allows for the distension of the urethra and bladder, enhancing the visibility of these structures during imaging.
  • Step 3: Imaging Acquisition - Once the contrast medium has been instilled, X-rays are obtained from one or more angles. This imaging captures the anatomy and any potential abnormalities within the urethra and bladder.
  • Step 4: Voiding Phase - After the initial imaging, the patient is allowed to void. This step is important as it helps to determine whether all the contrast medium has been expelled from the urinary tract.
  • Step 5: Post-Void Imaging - An additional X-ray is taken after the patient has voided. This final imaging step confirms the complete expulsion of the contrast medium and provides further insights into the urinary tract's function and structure.

3. Post-Procedure

After the urethrocystography, retrograde procedure, patients may be monitored for any immediate complications, although serious side effects are rare. It is common for patients to experience mild discomfort or a burning sensation during urination following the procedure due to the instillation of the contrast medium. Patients are typically advised to drink plenty of fluids to help flush out the contrast material from their system. A written report detailing the findings from the procedure is generated and provided to the referring physician for further evaluation and management of any identified conditions. Follow-up care may be necessary depending on the results of the urethrocystography and the specific clinical situation of the patient.

Short Descr X-RAY URETHRA/BLADDER
Medium Descr URETHROCYSTOGRAPHY RETROGRADE RS&I
Long Descr Urethrocystography, retrograde, radiological supervision and interpretation
Status Code Carriers Price the Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 1 - Diagnostic Tests for Radiology Services
Multiple Procedures (51) 0 - No 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) 0 - 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 T-Packaged Codes
ASC Payment Indicator Packaged service/item; no separate payment made.
Type of Service (TOS) 4 - Diagnostic Radiology
Berenson-Eggers TOS (BETOS) I1F - Standard imaging - other
MUE 1
CCS Clinical Classification 226 - Other diagnostic radiology and related techniques
26 Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
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).
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
TC Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles
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
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).
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.
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.
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.
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CR Catastrophe/disaster related
FY X-ray taken using computed radiography technology/cassette-based imaging
GW Service not related to the hospice patient's terminal condition
GY Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
GZ Item or service expected to be denied as not reasonable and necessary
LT Left side (used to identify procedures performed on the left side of the body)
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
RT Right side (used to identify procedures performed on the right side of the body)
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
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
Date
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2011-01-01 Changed Short description changed.
Pre-1990 Added Code added.
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