Urology Coding Alert

Remember that payer rules about bladder tumor removal coding vary.

When your urologist performs more than just a bladder neck contracture dilation during an operative session, figuring out the proper coding and when you can unbundled procedures can stump even the best coders. Test your know-how with this real-life case study.

Review the Surgical Case

Scenario: The urologist saw a Medicare patient who was in clot retention secondary to a bladder neck contracture and bleeding from bladder tumors. The urologist dilated the contraction and evacuated the clots. He also resected several medium-sized bladder tumors on the lateral bladder wall and fulgurated several small tumors at the bladder neck.

Coding dilemma: The code for the dilation of the contracture (52281, Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female) bundles all of the above procedures. Elizabeth Hollingshead, CPC, CMC, corporate billing/coding manager of Northwest Columbus Urology Inc. in Marysville, Ohio, who presented this case study, wondered if it would be appropriate to unbundled the following procedures and report them separately: 52001 (Cystourethroscopy with irrigation and evacuation of multiple obstructing clots) for the clot evacuation

52235 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of medium bladder tumor[s] [2.0 to 5.0 cm]) for the resection of the medium-sized bladder tumors

52214 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands) for the fulguration of the smaller tumors at the bladder neck.

Capture payment for multiple procedures in one session with these three tips.

1. Base Tumor Resection Code on the Payer

When your urologist removes multiple bladder tumors during one session, before choosing the appropriate codes, you must review your physician's documentation and also determine which payer  will be responsible for payment. Regardless of how many tumors your urologist removes, you usually report one code depending on the insurance carrier involved and the size of the tumors removed.

"You must remember in dealing with bladder tumors, billing is based on the size of the tumors and the number of tumors present," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. "With the latter, different carriers follow different payment rules when dealing with multiple tumor resections."

How it works: For Medicare, you should not add up the sizes of every tumor the physician removes -- in other words, the total volume of tumor removed. Instead, choose the code that represents the size of the largest single tumor removed. For private payers, add up the sizes of all tumors and choose the appropriate code based on this sum of the volume of tumor removed.

Warning: Since not all private payers follow this practice of adding up the tumor sizes and billing on total volume, you should check with each individual payer to see how they want you to report multiple bladder tumor removals.

In the above example, to Medicare report 52235 for the resection of the "medium"-sized tumors on the lateral wall. "Since these are the largest tumors, this code would also include the resection of the smaller multiple tumors at the bladder neck," Ferragamo adds.

For private carriers, add up the volume of tumor mass resected and/or fulgurated, and bill with one bladder tumor resection code appropriate for the tumor volume resected -- in this case most likely 52240.

2. Report Cystoscopic Clot Evacuation With 52001

For the cystoscopic examination and evacuation of blood clots from the bladder, you should report 52001. You must append modifier 59 (Distinct procedural service) to indicate that this cystoscopic procedure, although bundled into 52235, is a significant and separately reportable procedure and consequently also payable.

Medicare: If you're reporting this service to Medicare, as in this case study, list 52235 first. "CPT code 52235 is a higher paying code than 52001 and should be the primary procedure. CPT code 52001-59 is the secondary procedure, " Ferragamo explains.

3. Add 52281 If Payer Doesn't Follow CCI

CCI bundles 52281 into both the clot evacuation code and the bladder tumor removal code. Since CCI states that the bundles can never be bypassed with any modifier, you should not report 52281 to Medicare or any other payer that follows CCI guidelines.

Exception: If the payer does not follow CCI edits, however, then you should also report 52281. Again, append modifier 59 to indicate that this is a separately reportable procedure.

Note: "In addition, CPT code 52214 does not apply to fulguration of bladder tumors as in this case," Ferragamo says. "Since there are specific CPT codes (52224 to 52240) to bill for treatment of various sized bladder tumors (fulguration and/or resection), CPT code 52214 [Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands], should be billed primarily for fulguration of areas of bladder/ urethral bleeding, ulcerations, or infectious lesions."