Urinary Catheter Placement (Foley)
51702
[Urinary retention / bladder outlet obstruction / hemodynamic monitoring requiring strict I&Os / urinary incontinence with wound / perioperative monitoring / neurogenic bladder]
Same
Transurethral Foley urinary catheter placement
[Attending name], MD/DO
[Nurse/tech name]
None / [Intraurethral 2% lidocaine jelly]
The patient is a [age]-year-old [male/female] requiring urinary catheterization for [acute urinary retention / hemodynamic monitoring / perioperative management / wound care / urinary incontinence]. The risks, benefits, and alternatives were explained to the patient.
The urethra was patent and the catheter was advanced without resistance [or with [describe resistance]]. Return of [X] mL of [clear yellow / dark / bloody / cloudy] urine upon balloon inflation confirmed intravesical position. The bladder drained appropriately.
The patient was placed in the supine position. Standard sterile technique was used. The urethral meatus was cleansed with [betadine / chlorhexidine] swabs in a sterile fashion.
[Male technique:] The penis was held perpendicular to the body. [2% lidocaine jelly was instilled intraurethrally and held for 2–3 minutes.] A [16 Fr / 18 Fr] Foley catheter was lubricated and advanced through the urethral meatus, gently following the curve of the urethra. When the catheter hub was reached and urine was returned, the balloon was inflated with [10] mL of sterile water. The catheter was then gently retracted until resistance was felt, confirming balloon seating in the bladder neck.
[Female technique:] The labia were retracted to expose the urethral meatus. A [14 Fr / 16 Fr] Foley catheter was advanced through the meatus into the bladder. Urine return confirmed intravesical position and the balloon was inflated with [10] mL of sterile water.
The catheter was connected to a closed urinary drainage system. Urine output was recorded. The catheter was secured to the [inner thigh / leg] to prevent traction.
None
Urine [sent for urinalysis and culture / not sent]
None
[16 Fr / 18 Fr] Foley catheter, [X] mL urine drained, connected to closed drainage system
The catheter was functioning appropriately with adequate urine output. Urine character and output were communicated to the primary team.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Foley urinary catheter placement
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: None / intraurethral 2% lidocaine jelly
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX requiring urinary catheterization for ***. Risks and benefits explained.
FINDINGS: *** Fr Foley advanced without resistance. *** mL *** urine returned on balloon inflation. Bladder draining appropriately.
PROCEDURE:
Patient supine. Sterile technique. Meatus cleansed with ***. *** Fr Foley lubricated and advanced through meatus. Urine returned confirming intravesical position. Balloon inflated with 10 mL sterile water. Catheter retracted to resistance. Connected to closed drainage. Secured to leg.
COMPLICATIONS: None
DRAINS: *** Fr Foley, *** mL output
DISPOSITION: Catheter functioning, urine output communicated to primary team.
Signed: .ME, .MYDEGREE
.TODAYVariants
Difficult Placement: BPH / Urethral Stricture
Initial catheterization was unsuccessful due to [prostatic enlargement / urethral stricture / false passage]. A [Coudé-tipped catheter] was used with the curved tip directed anteriorly (12 o'clock) to navigate over the enlarged prostate. [Alternatively, a 14 Fr catheter was used to overcome stricture.] Urology was [consulted / not required] for catheter placement. The catheter was placed successfully without creation of a false passage.
Suprapubic Catheter (Percutaneous)
Given [inability to pass transurethral catheter / urethral trauma / urethral disruption / prior urologic surgery], a suprapubic catheter was placed. The bladder was confirmed distended by [palpation / ultrasound showing X cm of urine]. Under ultrasound guidance, a suprapubic catheter was inserted 2 cm above the pubic symphysis in the midline. Urine return confirmed intravesical position. The catheter was secured to the skin with suture. Urology was notified.
Charting Tips
- For male patients with difficult placement, document the catheter type used (Coudé vs standard), number of attempts, and whether urology was consulted. Forcing a catheter against resistance risks urethral trauma and false passage. Document that gentle technique was used.
- Document urine return confirming intravesical balloon inflation before inflating. Inflating the balloon in the urethra is a recognized complication causing urethral laceration. State explicitly that urine was returned prior to balloon inflation.
- For retention: document the volume drained and whether it was drained gradually (>400–500 mL at a time) to avoid post-obstructive diuresis monitoring requirements. Note initial post-drainage output and urine character.
Billing Tips
- Bill 51702 for simple temporary bladder catheterization (0.49 wRVU, 0-day global). Used for routine Foley placement in straightforward cases. Rarely billed separately in the inpatient setting, as it is typically included in the nursing/facility fee.
- Bill 51703 for complicated catheterization requiring special technique (1.43 wRVU, 0-day global). Use when catheterization requires a coude catheter, fluoroscopic guidance, or urologic instruments due to obstruction, stricture, or prior surgery. Document the complexity explicitly.
- In the outpatient or office setting, catheterization is billable as a separate procedure. In the inpatient hospital setting, routine Foley placement is almost always bundled into the global hospital charge and not separately billed by the physician.
- If a suprapubic catheter is placed instead, use 51040 (cystostomy with catheter, 4.65 wRVU) or 51102 (aspiration with catheter insertion). Do not use 51702/51703 for suprapubic access.
- Document the indication, technique, catheter size and type, and confirmation of urine output. This is required for medical necessity if billed separately.