Ask Dr. Z

Could you advise on CPT codes that should be used for this procedure? What do we need to look for in a retrograde cystourethrogram? "Retrograde cystourethrogram was performed via indwelling Foley. Scout imaging and fluoro images of the urethra and bladder were obtained during and following instillation of contrast through indwelling Foley. Fluoro cystogram was performed with contrast instilled in the bladder lumen via gravity flow through patient's indwelling Foley. Total of 225 mL of contrast was instilled into bladder lumen. No extraluminal contrast was visible to suggest postop leak. There was irregularity of the bladder dome near the reimplantation site during filling, which improved but did not resolve on further distention. Large volume reflux of contrast was seen in the left renal collecting system, and small volume reflux was seen into the right renal collecting system. Following evacuation, small post void residual was seen. No residual contrast seen."