Urology Coding Alert

If you're billing every cystoscopic bladder biopsy with fulguration that your urologist performs using CPT 52204 , you could be missing out on almost $400 per procedure. The answer to which bladder biopsy code you should be using lies within your urologist's documentation.

Read on to find out what clues to look for to ensure you choose the proper code every time.

Myth: Code 52204 (Cystourethroscopy, with biopsy[s]) is the only code you can use to report a cystoscopic bladder biopsy and fulguration.

Fact: Which bladder biopsy code you report depends on the reason for the fulguration and the information your urologist provides in his operative report. You will then choose from the following bladder biopsy codes:

• 52204 --" Cystourethroscopy, with biopsy(s)

• 52224 --" Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy

• 52234 --" Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)

• 52235 --" ... MEDIUM bladder tumor(s) (2.0 to 5.0 cm)

• 52240 --" ... LARGE bladder tumor(s)

If the urologist did a biopsy and fulgurated a bleeder within the biopsy site without treatment of a lesion, you should only report 52204, as this code also includes the fulguration. "If fulguration is used only to stop bleeding from the biopsy site, it's included in the biopsy and you would bill 52204," explains Elizabeth Hollingshead, CPC, CMC, corporate billing/coding manager of Northwest Columbus Urology Inc. in Marysville, Ohio.

On the other hand, if you're "treating" a small lesion less than 0.5 cm in size with biopsy and complete fulguration, code 52224. In other words, if the physician biopsied a minor lesion and then fulgurated its base or any remaining part of the lesion, use 52224.

Example: The urologist documents that he performed a bladder biopsy of "a suspicious area" and only performed fulguration to stop the bleeding from the biopsy site in that area. Note that he does not document anything about treating a lesion or the size of a lesion.

For this example you should report 52204, Hollingshead says.

If, however, your urologist documented that he performed a cystoscopic bladder biopsy with fulguration to completely treat and eradicate a lesion that measured 0.3 cm, you would report 52224. "If the entire lesion is being fulgurated to remove it, you use 52224," Hollingshead explains. Remember that your code choice depends on the size of the lesion, she adds. A bigger lesion would lead to codes 52234-52240.

The result: If you automatically assign 52204 when your urologist states he used fulguration during a bladder biopsy, you're costing your practice money. The unadjusted national Medicare 2009 fee for 52204 is $453.72 (12.58 RVUs times the 2009 conversion factor of $36.0666), whereas the fee for 52224 is $850.45 (23.58 RVUs times the 2009 conversion factor of $36.0666).

If you report 52204 in the example where the urologist treated a 0.3 cm lesion with fulguration, you would be shortchanging the physician by almost $400 (when your urologist performs these procedures in the office).

Don't forget: Use 52214 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands) for fulguration of a bleeding vessel(s) in the bladder, such as in a case of radiation cystitis (no biopsy) or the treatment/fulguration of a Hunner's ulcer associated with interstitial cystitis.