Oncology & Hematology Coding Alert

Question: Please provide directions for reporting ‘history of bladder cancer’ versus ‘bladder tumor of unspecified nature.’ One criterion for reporting the ‘history’ code is when a patient no longer has the cancer and is no longer receiving treatment. We are seeking clarifications for reporting the diagnosis of bladder cancer during the cystoscopy protocol. When a patient has been diagnosed with bladder cancer, the protocol is cystoscopy every three months for a couple of years, then every six months, and last every year. All along the patient is being monitored, and should the bladder cancer code still be used until the patient is in the yearly cystoscopy stage?

What is the best approach when a patient returns for a six-month surveillance cystoscopy, and a recurrent bladder tumor is found? There isn’t still a pathology report with us to confirm if the tumor was malignant. Do we only use D49.4 or both D49.4 and Z85.51?

Oregon Member

Answer: You should use Z85.51 (Personal history of malignant neoplasm of bladder) for the medical reason or necessity for performing the cystoscopic examination, and D49.4 (Neoplasm of unspecified behavior of bladder) for an E/M service billed on face to face time during which your physician counsels the patient and coordinates his future care including preoperative evaluation and type of surgical care necessary to treat the newly discovered bladder tumor.

You should also attach modifier 25 (Significant, separately identifiable Evaluation and Management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code for payment of this counseling and the coordination of care.

Remember: You should only use the Z85.51 code, when there is no clinical, endoscopic, or laboratory evidence of bladder tumor and when you are no longer providing active treatment of the tumor. Basing your diagnosis code on the time frame of a cystoscopic examination is not correct coding.