Urology Coding Alert

Your urologist removes multiple bladder tumors during one session. You should report multiple codes, right? Not so fast. You need to review your physician's documentation and pay attention to which payer you're reporting the procedure to before choosing your codes. Follow these expert pointers and you're sure to code right every time.

When your urologist transurethrally removes tumors from a patient's bladder, your first step in choosing a code to report is to refer back to the physician's documentation.

Look for notations about the size of the bladder tumor(s).

CPT offers you four bladder tumor removal codes. As the code descriptors indicate, which code you report depends on the size of the tumor. In the documentation, your urologist should make a visual estimate of the size of the bladder tumor. Based on the size estimate documented, select one of four codes:

• Use 52224 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] or treatment of MINOR [less than 0.5 cm] lesion[s] with or without biopsy) for tumors measuring less than 0.5 cm

• use 52234 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; SMALL bladder tumor[s] [0.5 up to 2.0 cm]) for 0.5 cm to 1.9 cm sized tumors

• use 52235 (... MEDIUM bladder tumor[s] [2.0 to 5.0 cm]) for tumors measuring 2.0 cm to 5.0 cm

• use 52240 (... LARGE bladder tumor[s]) for tumors  5.0 cm or larger.

As you know, coding for multiple procedures doesn't always equal multiple codes. That's the case in coding for transurethral resection of multiple bladder tumors.

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 can only bill for one tumor," says Tina Lee, CPC, coding specialist with Urology Associates of Central California in Fresno. "If my docs indicate size I bill for the largest." "It's my understanding that if there are multiple tumors, you should code the size of the largest tumor," agrees Jeri Williams, administrative assistant with Urology Associates of Mobile in Alabama.

How it works: For Medicare, you should not add up the sizes of every tumor the physician removes. Instead,choose the code that represents the size of the largest single tumor removed.

"Some private carriers, not all, will allow you to add up the tumors and get a larger size," says Shannon McGough, CMC, who works in Hospital Census in Texarkana, Texas. Therefore, for private payers, you should add up the sizes of all the tumors and choose your code based on this sum.

Tip: Since not all private payers allow this practice of adding up the tumor sizes, you should check with each individual payer to see how they want you to report multiple bladder tumor removals.

Example 1: Your urologist removes a 2 cm tumor and a 5 cm tumor. For Medicare, you'll use 52240 since the largest tumor fits the large-tumor code description. For private carriers, you'll still report 52240 since the tumor sizes add up to 7 cm.

Example 2: A patient has three tumors, one of which is 3 cm and two that are 1 cm each. When your urologist removes all three lesions, you should report 52235 to Medicare because the 3 cm tumor is largest. When you add up the sizes of the three tumors, you'll see that you should report a different code --52240 -- to private carriers because the tumors add up to 5 cm.

Example 3: The urologist transurethrally resects five 1 cm tumors at one sitting. For Medicare, bill 52234 for the resection of a 1 cm tumor, the largest tumor present.

On the other hand, for private carriers, add up the sizes of the tumors and bill 52240 based on the sum of all tumors removed, or 5 cm.

Exception to the rule: When you're billing Medicare or private carriers for the resection (removal) of a bladder tumor 0.5 cm or larger and also for the resection of a minor bladder tumor (less than 0.5 cm in size) at the same sitting, bill the following:

• 52235 for the 2-5 cm bladder tumor, and

• 52224-59 for the minor tumor resection. Add modifier 59 to bypass the edits bundling 52224 with the other bladder tumor resection codes.

When your urologist removes multiple tumors, you may think you should report the procedure code and append modifier 22 (Increased procedural services) to capture extra reimbursement. While it seems logical to consider this option because the physician does more work removing multiple tumors than he does when he removes just one, you should refrain from using modifier 22.

Here's why: The CPT code descriptors for 52224-52240 state "tumor(s)" or "lesions(s)," meaning that each code represents single or multiple tumors of the same size.

Therefore, you cannot expect additional reimbursement when your urologist removes more than one tumor.

If your urologist performs a bladder biopsy before removing a bladder tumor, under certain circumstances, you may be able to separately report both the biopsy and the tumor removal. Again, the size of the tumor and the location of the biopsy will determine your coding.

The catch: Code 52224 specifies "with or without biopsy," so if your urologist performs a biopsy before removing a tumor that is smaller than 0.5 cm, you cannot report both services. In this case, because of the small size of the tumor, a biopsy often removes the tumor completely, and therefore you should only report code 52224 for both the treatment and the biopsy of the lesion. The Correct Coding Initiative (CCI) reinforces this by bundling 52204 (Cystourethroscopy, with biopsy[s]) into 52224, and you can't ever use a modifier to bypass this bundling edit.

Alternative: If the tumor is larger than 0.5 cm and you report 52234, 52235, or 52240, you can separately report a bladder biopsy under certain circumstances. If the urologist biopsies normal mucosa (mapping) or a bladder red patch, or only biopsies another bladder tumor and each are in distinct areas and in a bladder location separate and different from the initial tumor, report the biopsy separately. Use 52204 and append modifier 59 (Distinct procedural service) to indicate that the biopsy was a separate procedure at a separate site. CCI also bundles 52204 into the resection codes 52234, 52235, and 52240, but you can bypass these bundles with modifier 59 since they have a modifier indicator of "1."

Beware: If your urologist performs a biopsy of the tumor itself prior to its resection or biopsies the tumor base, or the immediate surrounding area after the resection of the lesion, you should not report a separate biopsy service. These biopsies would be included in the resection codes. Therefore, you should report just the resection (52234-52240).

Note: In the past you also were able to report multiple bladder biopsies by coding 52204 multiple times. "We used to be able to bill for each biopsy," Lee says. "However,that is also no longer true." Most insurance carriers, including Medicare, will reimburse for only one biopsy no matter how many biopsies you perform.

When multiple biopsies significantly prolong an operative procedure, you might consider billing 52204 with modifier 22 and seeking extra payment with the appropriate documentation. But this should be a rare occurrence, as many private carriers and Medicare rarely reimburse for multiple bladder biopsies.

"At one time I was coding 52204 with a 22 modifier, but that didn't help us to get paid any differently, " Williams confirms.