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 233.7 (carcinoma in situ of breast and genitourinary system; bladder) or 188.x (malignant neoplasm of bladder).

Many urologists wait to decide how to code the diagnosis until the pathology comes back, says Laura Siniscalchi, RHIA, CCS, CCS-P, CPC, senior consultant with the Boston branch of Deloitte and Touche, an auditing consultancy. A lesion could be a malignant tumor, but it could be benign (for that matter, a tumor can be benign too, at least for CPT coding. See box below.). Pathology is only important, in coding terms, when you want to call something a malignant tumor. The diagnosis code is whats important. The procedure code is irrelevant to the morphology of the lesion. If I were auditing someone, and they used the word lesion and coded for a 52204 or 52224, I wouldnt worry about waiting for the pathology, Siniscalchi says.

The issue of what ICD-9 code to use, and whether to wait for the pathology report before picking the diagnosis code (and therefore the procedure code as well), is best dealt with by relying on clinical evidence: the physicians opinion.

Whether you wait for the pathology report to select the diagnosis code will depend on whom you talk to, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a consultancy based in Denver. If you talk to a surgeon, he or she will say that because of their experience, they can normally determine the pathology of the lesion by gross visual examination, Page says. Coders, on the other hand, will opt to wait for the report before assigning the diagnosis code. If waiting for the pathology report is not an option, the unspecified neoplasm code is used by default. For reimbursement purposes, it usually doesnt matter, Page says. It has not been our experience that medical-necessity denials due to the diagnosis are an issue.

Coding a Biopsy for Occult CIS

Biopsy (52204) of the normal bladder mucosa for occult CIS needs a special diagnosis. Ferragamo recommends an infrequently used but payable V code V71.1 (observation and evaluation for suspected conditions not found; observation for suspected malignant neoplasm) as the most accurate diagnosis available under this clinical scenario, prior to biopsy report.