Urology Coding Alert

The urologist often does a biopsy of a small lesion in the bladder and a tumor removal at the same time, but cannot bill both codes together. During the biopsy, the entire lesion or tumor may be removed, creating a coding challenge for urologists. Sometimes the area around them must be cauterized to prevent bleeding, creating more work. And with a history of carcinoma in situ, it is particular important to biopsy suspicious-looking areas.

Medicare and most commercial payers will not reimburse for the biopsy of a lesion and its removal (excision) at the same session, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York in Stonybrook, and a urology coding trainer. In general, much depends on whether there is a visible lesion, and on the size of the lesion, he says.

For a strict biopsy, use 52204 (cystourethroscopy, with biopsy). For example, if no lesions are visible, and the urologist is biopsying what appears to be normal mucosa (for mapping of the bladder or in the face of a positive cytology), use 52204, Ferragamo says. Also use 52204 if only a biopsy of a visible lesion is performed, with no attempt to remove the tumor.

Size Dictates Code

Codes 52224-52240 are used for the removal of lesions/tumors of increasing size. The size of the lesion/tumor dictates the particular code used.

When removing and biopsying and/or fulgurating with or without biopsy a small lesion/tumor (less than 0.5 cm), 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). Use 52234 ( and/or resection of; SMALL bladder tumor[s] [0.5 to 2.0 cm]), 52235 ( MEDIUM bladder tumor[s] [2.0 to 5.0 cm]) or 52240 ( LARGE bladder tumor[s]) for the removal of increasingly larger lesions/tumors.

If a transurethral resection of a bladder tumor is incomplete, but is more than just a biopsy, use the CPT code related to the size, and add modifier -52 (reduced services) or -53 (discontinued procedure). For example, if a urologist incompletely resects a tumor that is larger than 5 cm, use 52240 with modifier -52 or -53. You cant bill both removal and biopsy at the same time, Ferragamo says.

When to Assign a Diagnosis Code

ICD-9 diagnoses should reflect your knowledge of the lesion, Ferragamo says. If you do not know the pathology, use 236.7 (neoplasm of uncertain behavior of genitourinary organs; bladder) or 239.4 (neoplasms of unspecified nature; bladder). If you bill after the pathology is known, use [...]