Urinary Catheter Placement (Foley)

2026 Medicare PFS: 0.49 wRVU · 0-day global
wRVU0.49
Global0-day
ApproachBedside
ComplexityRoutine
Procedure:

Transurethral Foley urinary catheter placement

Indication:

[Acute urinary retention / Bladder outlet obstruction / Neurogenic bladder / Critical illness requiring strict urine output monitoring / Perioperative monitoring / Open sacral or perineal wound with urinary incontinence] requiring indwelling urinary catheterization.

Consent:

[Informed consent was obtained from the [patient / patient's surrogate] after discussion of risks, benefits, and alternatives / The procedure was emergent, and consent was implied].

Performed By:

[***, MD/DO]

Anesthesia:

[None / Intraurethral 2% lidocaine jelly]

Findings:

The urethra was patent, and the catheter advanced [without resistance / with resistance at the [location]]. Urine returned before balloon inflation, confirming intravesical position, and [X] mL of [clear yellow / dark / bloody / cloudy] urine drained.

Description of Procedure:

A time-out was completed confirming the patient and procedure. The patient was positioned supine, and sterile technique was used. The urethral meatus was cleansed with [sterile saline / aqueous chlorhexidine 0.05% / povidone-iodine].

[2% lidocaine jelly was instilled intraurethrally and held for 2–3 minutes.] [The penis was held perpendicular to the body, and the lubricated catheter was advanced through the meatus to the hub, gently following the curve of the urethra / The labia were retracted to expose the urethral meatus, and the lubricated catheter was advanced through the meatus into the bladder].

After urine return confirmed intravesical position, the balloon was inflated with sterile water. The catheter was gently withdrawn until resistance was felt, confirming balloon seating at the bladder neck. The catheter was connected to a closed urinary drainage system and secured to the [inner thigh / leg] to prevent traction.

Device Placed:

[X] Fr Foley catheter, balloon inflated with [10] mL sterile water, to closed drainage

Estimated Blood Loss:

None

Specimens:

[Urine sent for urinalysis and culture / None]

Complications:

None

Post-Procedure Plan:

The catheter is draining well. Urine output and character were communicated to the primary team. [Urine output will be monitored for post-obstructive diuresis.] [Catheter necessity will be reassessed daily.]

Epic SmartPhrase Version 
PROCEDURE: Transurethral Foley urinary catheter placement
INDICATION: *** requiring indwelling urinary catheterization.
CONSENT: [Informed consent obtained from the [patient / surrogate] after discussion of risks, benefits, and alternatives / Emergent, consent implied].
PERFORMED BY: ***, MD/DO
ANESTHESIA: [None / Intraurethral 2% lidocaine jelly]

FINDINGS: Urethra patent, catheter advanced without resistance. Urine returned before balloon inflation, confirming intravesical position. *** mL *** urine drained.

PROCEDURE DETAILS:
Time-out completed. Patient supine. Sterile technique. Meatus cleansed with ***. [Lidocaine jelly instilled and held 2–3 minutes.] [Penis held perpendicular, Foley lubricated and advanced through meatus to the hub / Labia retracted, Foley lubricated and advanced through meatus into the bladder]. Urine returned confirming intravesical position. Balloon inflated with sterile water. Catheter withdrawn to resistance. Connected to closed drainage. Secured to [inner thigh / leg].

DEVICE PLACED: *** Fr Foley, balloon *** mL sterile water, to closed drainage
EBL: None
SPECIMENS: [Urine sent for UA and culture / None]
COMPLICATIONS: None
POST-PROCEDURE PLAN: Catheter draining well. Urine output and character communicated to primary team. [Monitor for post-obstructive diuresis.] [Catheter necessity reassessed daily.]

Signed: .ME, .MYDEGREE
.TODAY
Variants

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
  1. 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.
  2. 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.
  3. Alcohol-based antiseptics are avoided on the urethral meatus because they irritate the mucosa.
  4. Document that the indication meets CDC HICPAC CAUTI appropriate-use criteria:
    • Acute urinary retention or obstruction
    • Critical illness requiring accurate urine output
    • Select perioperative indications
    • Open sacral or perineal wound in an incontinent patient
    • Prolonged immobilization
    • End-of-life comfort care

    Urinary incontinence alone without an open wound is not an appropriate indication. Use the smallest catheter size that provides adequate drainage.

  5. For urinary retention: the bladder can be drained rapidly and completely. Current evidence (Nyman et al. Mayo Clin Proc 2010; Boettcher et al.) does not support gradual or clamped drainage, which was historical practice not confirmed by controlled trials. Document the initial drained volume and monitor urine output post-drainage for post-obstructive diuresis (more than 200 mL/hr for 2 or more consecutive hours), which is triggered by the obstruction itself, not by drainage speed.
Documentation & Reimbursement Considerations
  1. Primary service: Report Urinary Catheter Placement (Foley) as the primary service when it is the definitive operation performed.
  2. Simple temporary bladder catheterization (0.49 wRVU, 0-day global) covers routine Foley placement in straightforward cases. It is rarely billed separately in the inpatient setting, as it is typically included in the nursing/facility fee.
  3. Complicated catheterization (1.43 wRVU, 0-day global) is reported when catheterization requires a coude catheter, fluoroscopic guidance, or urologic instruments due to obstruction, stricture, or prior surgery. Document the complexity explicitly.
  4. 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.
  5. Suprapubic catheter placement is reported with cystostomy or aspiration-with-catheter services (4.38 and 2.63 wRVU), not the urethral catheterization services.
  6. Document the indication, technique, catheter size and type, and confirmation of urine output. This is required for medical necessity if billed separately.

ⓘ General Documentation & Reimbursement Considerations →