Urology Coding Alert

If you're not differentiating bladder biopsy codes CPT 52204 and CPT 52224 from their related bladder tumor resection codes, 52234-52240, you're not getting paid in full. Take a look at the scenario below, which shows how these services can be billed separately.

The scenario: After obtaining informed consent, a 68-year-old Medicare patient was prepped and draped in the usual fashion. The patient was put in the dorsal lithotomy position and was administered general anesthesia. Transurethral resection instruments were inserted and two tumors were seen, one on the right lateral wall and one on the dome. The tumor on the right lateral wall measured 3 cm, and the tumor on the dome measured less than 0.5 cm. These tumors were resected down to and including bladder wall tissue. Documented tumors: a medium tumor on the right lateral wall (188.2) and a minor tumor on the dome (188.1)

Coding solution: For this scenario, you should report codes CPT 52235 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; MEDIUM bladder tumor[s] [2.0 to 5.0 cm]) and 52224-59 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] or treatment of MINOR [less than 0.5 cm] lesion[s] with or without biopsy; Distinct procedural service), says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York, Stony Brook.

Code 52235 accounts for the resection of the largest bladder tumor, in this case a tumor of medium size, and the resection of any small or medium tumors resected during that surgical session. However, code 52235 does not account for the resection of an additional, separate minor tumor(s).

Whether you can separately report the resection of a minor tumor has been a point of lingering confusion, Ferragamo says. Many coders mistakenly assume the policy that says only one of the bladder tumor resection codes (52234-52240) can be reported in a single surgical session also includes codes 52204 (Cystourethroscopy, with biopsy) and 52224 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] or treatment of MINOR [less than 0.5 cm] lesion[s] with or without biopsy).

While Medicare instructs coders to report only one of the three bladder tumor resection codes 52234, 52235 and 52240 Medicare does not indicate that this "one-code-only" rule applies to the bladder biopsy codes, 52204 and 52224, Ferragamo says.

According to the Medicare Carriers Manual, "The descriptors for codes 52234 through 52240 include the language 'tumor(s)'. This means that regardless of the number of tumors removed, only one unit of a single code can be billed on a given date of service. It is inconsistent to allow payment for removal of a small (code 52234) and a large (52240) tumor using two codes when only one code is allowed for the removal of more than one large tumor. For these three codes, only one unit may be billed for any of these codes, only one of the codes may be billed, and the billed code reflects the size of the largest tumor removed."

"If performed at the same encounter, codes 52204 or 52224 can be billed separately along with either code 52234, 52235 or 52240," Ferragamo says, as long as you append modifier -59 and the procedures were performed for separate bladder lesions or tumors. Modifier -59 indicates that the biopsy was taken of a separate and distinct bladder lesion from and not related to the larger resected tumor, and breaks the bundle between code 52224 and 52235 to allow payment for both codes. In this case, the diagnosis codes support the use of modifier -59 by indicating that 52235 and 52224 were performed in separate sites in the bladder 188.2 is linked to code 52235, and 188.1 is linked to code 52224.

Beware: For private carriers, experts agree that you must tailor your coding to the carrier's policy for submitting claims for the resection of multiple bladder tumors of different sizes. Many private payers prefer that you add up the bladder tumor sizes and choose the code for the resection of their combined sizes (volume) rather than report only the code for the largest tumor resected. In other words, if a urologist resects a 0.6-cm bladder tumor (small) and a 4.8-cm bladder tumor (medium) during a surgical session, you would report 52240 because their combined size is 5.4 cm, which is considered a large bladder tumor. Other carriers may have different coding requirements, so it is a good idea to check with your carrier before submitting the claim and make sure you have that policy in writing.