74400

Urography (pyelography), intravenous, with or without KUB

Intravenous Urography (IVU), also referred to as intravenous pyelography (IVP), is a specialized radiographic examination of the kidneys, ureters, and urinary bladder. The procedure involves the administration of a radiopaque iodinated contrast medium into the patient's venous system. Once injected, the kidneys filter the contrast from the bloodstream and concentrate it within the renal tubules, allowing for the progressive visualization of the urinary tract anatomy. The examination typically begins with a preliminary 'scout' film, commonly known as a KUB (Kidney, Ureter, Bladder), which serves to identify any pre-existing radiopaque calculi, abnormal calcifications, or bowel gas patterns that might obscure findings. Following the administration of contrast, a series of timed radiographs are obtained at specific intervals. The initial films, often called the nephrogram phase, allow for the evaluation of the renal parenchyma and cortical contour. Subsequent films, known as the excretory phase, demonstrate the collecting systems, including the minor and major calyces, the renal pelvis, the course and caliber of the ureters, and the filling of the urinary bladder. This procedure is instrumental in assessing renal excretory function, identifying structural anomalies, detecting obstructions such as stones or strictures, and evaluating filling defects caused by neoplasms. While modern cross-sectional imaging like CT urography has become more common, CPT 74400 remains a valuable diagnostic tool for detailed mucosal visualization and when specialized functional assessment is required. The physician must monitor the patient throughout for potential adverse reactions to the contrast media and interpret the morphological and functional data captured across the timed series of images.

Clinical Indications

  • Gross or microscopic hematuria
  • Suspected urolithiasis or nephrolithiasis
  • Evaluation of congenital anomalies of the urinary tract
  • Unexplained flank pain
  • Recurrent urinary tract infections
  • Follow-up of hydronephrosis or ureteral obstruction
  • Assessment of renal trauma
  • Identification of renal or ureteral filling defects
  • Pre-operative mapping of urinary anatomy

Procedure Steps

  1. Obtain patient consent and confirm absence of contraindications such as contrast allergy or severe renal insufficiency.
  2. Perform a preliminary scout radiograph (KUB) to establish baseline anatomy and check for radiopaque stones.
  3. Establish intravenous access via peripheral vein.
  4. Administer the appropriate dose of iodinated contrast medium (ionic or non-ionic).
  5. Perform an immediate post-injection radiograph to capture the nephrogram phase (renal parenchyma).
  6. Capture timed interval radiographs (e.g., 5, 10, and 15 minutes) to visualize the opacified collecting system and ureters.
  7. Apply abdominal compression if necessary to better distend the upper collecting systems for clearer imaging.
  8. Capture a late-phase radiograph to visualize the contrast-filled urinary bladder.
  9. Perform a post-void radiograph if needed to assess bladder emptying and distal ureteral anatomy.
  10. Review all images for diagnostic quality and monitor the patient for any immediate or delayed allergic reactions.

Coding Guidelines

  • Code 74400 includes the preliminary KUB; do not report 74018-74022 separately for the scout film.
  • If tomography is performed in addition to the standard IVP, use code 74405 instead of 74400.
  • The contrast material used is reported separately using appropriate HCPCS Level II codes (e.g., Q9967).
  • For the professional component only (physician interpretation), append modifier 26.
  • For the technical component only (facility/equipment), append modifier TC.
  • Do not report 74400 in conjunction with codes 74410 or 74415.
  • If the procedure is converted to a CT urography, report the appropriate CT code (e.g., 74178) instead of 74400.
  • Medical necessity must be documented for the use of contrast, particularly if non-ionic contrast is utilized.

Associated ICD-10 Codes