General Surgery Coding Alert

Question: Our surgeon took a bladder biopsy using a cystoscope and in the op report, described the specimen as “an adherent stone-like structure with calcification affixed to the right lateral bladder wall, measuring 3.4 mm.” The pathology report gives a diagnosis of “transitional cell carcinoma.” What diagnosis and procedure codes should we use?

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Answer: You should code the diagnosis to the highest degree of specificity possible, which means reporting an ICD-10-CM code based on the pathologist’s final diagnosis, not based on the surgeon’s description.

The correct diagnosis code for transitional cell carcinoma of the bladder, also called urothelial carcinoma, is C67- (Malignant neoplasm of bladder).

Although you should not report the surgeon’s less-specific findings using a code such as D49.4 (Neoplasm of unspecified behavior of bladder), you do need to use the surgeon’s identification of the tumor anatomic site to assign the most specific ICD-10 code. The final diagnosis for this case should be C67.2 (Malignant neoplasm of lateral wall of bladder).

The appropriate procedure code for this case is 52204 (Cystourethroscopy, with biopsy(s)).