2025 CPT code 51798
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Surgery - Urodynamic Procedures on the Bladder Surgery Feed
Measurement of post-void residual urine and/or bladder capacity using non-imaging ultrasound.
Modifiers 51 (multiple procedures) and possibly others depending on the circumstances of service delivery (e.g., 25 for E/M services on the same day) might apply.
Medical necessity for 51798 is established when there's a clinical indication for assessing PVR, such as suspected urinary retention, post-operative evaluation of bladder emptying, or management of neurogenic bladder dysfunction. The test should not be performed more than once daily.The results must be clinically relevant for guiding management decisions.
The clinical responsibility lies with the physician or qualified healthcare professional performing and interpreting the ultrasound.This includes patient preparation, ultrasound performance, measurement interpretation, and documentation.
In simple words: This ultrasound test measures how much urine is left in your bladder after you pee. A small ultrasound device is placed on your lower belly to get a measurement, helping doctors see if you're having trouble emptying your bladder.
CPT code 51798 represents the measurement of post-void residual (PVR) urine volume and/or bladder capacity utilizing non-imaging ultrasound.The procedure involves the use of a portable ultrasound device to assess the amount of urine remaining in the bladder after urination. This measurement aids in diagnosing urinary retention and guiding further treatment decisions, such as catheterization.
Example 1: A patient complains of urinary frequency and hesitancy.A PVR ultrasound (51798) is performed revealing a high residual volume, leading to catheterization for bladder emptying., Post-prostatectomy, a patient experiences incomplete bladder emptying.A 51798 is used to quantify the PVR, guiding decisions regarding further management, such as intermittent self-catheterization., A patient with a neurogenic bladder undergoes a 51798 to assess bladder emptying efficacy. The results inform decisions on bladder management strategies, such as medication adjustments or intermittent catheterization.
* Indication for the ultrasound (e.g., suspected urinary retention, post-surgical evaluation).* Patient preparation (e.g., voiding before the exam).* Ultrasound technique and equipment used.* Measured PVR volume and bladder capacity.* Physician interpretation of the results and any clinical decisions made based on the findings (e.g., decision to catheterize).
** The ultrasound machine used should be capable of providing a measurement of residual urine volume.Documentation should clearly indicate that the measurement was obtained via ultrasound and should include the exact quantity of residual urine measured.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- RVU: The RVUs for this code will vary based on geographic location, facility type, and payer. Consult the appropriate fee schedule for specific values.
- Global Days: This code does not have a defined global period.Billing is typically for the single procedure.
- Payment Status: Active
- Modifier TC rule: No TC modifier is applicable to this code, as there is no separate technical component.
- Fee Schedule: Historical fee schedule data is not provided.Consult payer-specific fee schedules for historical data.
- Specialties:Urology
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center