漫香阁

Learn how to report multiple tumor resections.

As a urology coder, you should pay careful attention when reviewing operative reports for the treatment of suspicious areas in the bladder. The patient could present with hematuria to the urologist鈥檚 office. After diagnostic laboratory tests, a urologist will perform a cystourethroscopy to view the bladder for areas of concern. The CPT^庐 code book contains several procedure codes to report bladder biopsies and treatment of suspicious bladder lesions.

Read on to learn how to report the procedures and what the documentation must include.

Report a Biopsy Via Cystourethroscopy

You鈥檒l assign 52204 (Cystourethroscopy, with biopsy(s)) to report the billing of a cystoscopy with biopsy of the urethra and/or bladder. Bill this code only one time no matter how many biopsy specimens are collected and regardless of how the specimens are sent to pathology. The AMA documented in the September 2003 issue of CPT^庐 Assistant that you should bill 52204 only once, and this information was later confirmed with a 2006 descriptor change.

Familiarize Yourself With Fulguration

At times, the urologist may need to perform fulguration during the cystourethroscopy. According to the National Cancer Institute (NCI) at the National Institutes of Health (NIH), fulguration is a procedure where the healthcare provider 鈥渦ses heat from an electric current to destroy abnormal tissue, such as a tumor or other lesion. It may also be used to control bleeding during surgery or after an injury.鈥�

You鈥檒l report 52214 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands) when the provider stops bleeding by fulgurating the trigone, bladder neck, prostatic fossa, urethra, or periurethral glands. You should bill this code only once, even if several areas in the bladder and surrounding tissues have been fulgurated.

However, if a biopsy is performed and the area of the biopsy needs to be fulgurated, do not report 52214. The fulguration is inherently included in 52204.

Assign 52224 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy) when the provider performs fulguration of the bladder or the treatment of minor lesion(s) in the urethra or bladder during cystourethroscopy with or without collection of biopsy specimens.

Pay careful attention to the use of 鈥渓esion(s)鈥� catch-all in the code descriptor, which describes that you鈥檒l use this code one time only no matter how many minor lesions are treated. Also, the same reasoning applies for the number of biopsy specimens removed in conjunction with this procedure. If biopsy specimens are collected at the same time as the fulguration/treatment, use 52224 only. This code is used regardless of how the treatment is performed, (cryo, laser, etc.). You鈥檒l report 52224 when the urologist performs both the biopsy and fulguration.

Base Your Code Selection on Tumor Size

When the urologist treats or removes tumors in the bladder, the documentation must include the sizes of the tumors. This information is necessary to assign the correct cystourethroscopy code related to the tumor resection size. These codes include:

• 52234 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm))
• 52235 (鈥� MEDIUM bladder tumor(s) (2.0 to 5.0 cm))                  
• 52240 (鈥� LARGE bladder tumor(s))

Use these codes to report fulguration or resection of small, medium, and large bladder tumors.  Again, you鈥檒l report the applicable code no matter how many bladder tumors the provider removed.

Important: Make sure the physician documents the size of the largest tumor in the operative note and don鈥檛 rely on the pathology report for the size of the tumor. Once a specimen is placed in the transport solution, it will shrink. The pathologist is measuring the specimen from the specimen vial. The size documented by the pathologist can mean the difference between reporting a small, medium, or large tumor surgery code.

If a biopsy is performed in a different area from the removal of bladder lesion(s) and not directly adjacent to the bladder lesion removal, both CPT^庐 codes 52204 and 52234, 52235, or 52240 may be reported. According to the National Correct Coding Initiative (NCCI) edit for Medicare, you鈥檒l append modifier 59 (Distinct procedural service) to the bladder lesion code if both procedure codes are reported.

The bladder tumor size is important when determining the difference in reporting 52234 or 52235, where one of the codes is for tumors up to 2 cm and the other is for tumors from 2 cm to 5 cm in diameter.

For Medicare, if more than one tumor is removed, then use the largest size tumor recorded to report the appropriate size code. Some commercial payers may allow billing differently, such as adding the sizes together and billing the cumulative size. This is a payer-by-payer determination. The best practice is to check with the individual payer for the specific policy instructions.

Finally, if several tumors are removed and the procedure takes longer due to the number of tumors, you may append modifier 22 (Increased procedural services) to the appropriate CPT^庐 code based on size. Make sure the documentation supports the amount of time and number of tumors removed to indicate that a procedure or service is significantly greater than usually required.

Provider documentation is key in determining the correct CPT^庐 code to report bladder biopsies and tumors.

Stephanie N. Stinchcomb Storck, CPC, CPMA, CUC, CCS-P,
longtime urology coding expert, Summerfield, Florida