Urology Coding Alert

Size matters more than quantity.

Performing a cystourethroscopy is standard fare for urologists, but don’t let commonplace lead to coding complacence. Ensure you’re ready for a different twist to the situation, such as coding for removal of a bladder tumor during the cystoscopic examination.

Start With the Correct Codes

During a cystoscopic examination with fulguration (destruction) of small lesions or tumors, the urologist inspects the urethra, prostatic urethra (in men), the interior of the bladder, and ureteric openings. He/she inserts the tip of the cystoscope into the urethra and slowly guides it up and into the bladder. The camera attached to the cystoscope allows the urologist to view images of the bladder interior on a monitor screen.

The urologist inserts special instruments through the cystoscope to destroy any lesions found in the bladder. Lesion destruction is achieved through either high-frequency electric current, cryosurgery (intense cold), or laser therapy.

To code the encounter, your options are as follows:

• 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]).

Pay Attention to Size

The urologist will make a visual estimate of the size of a tumor during the cystourethroscopy. You will select the best code for the procedure based on the documented lesion size, as designated for each code.

Special note: For Medicare insurance no matter how many tumors the urologist removes, you should only report a single code for the encounter. Remember Medicare makes it clear that you are not coding correctly if you report more than one removal code or add up the sizes of the individual tumors. Instead, choose the code that represents the size of the largest single tumor removed.

For private payers, you should add up the sizes of all the tumors and choose your code based on the sum of all the tumors removed, says Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook.

Example 1:  Your urologist removes a 1-cm tumor and a 5-cm tumor. For Medicare, you will bill 52240 since the largest tumor fits the large-tumor code description. For private carriers, you will also report 52240 since the tumor sizes add up to 6 cm.

Example 2: For another patient, the physician removes three small tumors that he documents as being 1 cm each. Because all of the tumors are the same size, you should use code 52234 in this situation for Medicare. For private payers, add up all the tumors and bill 52235 for a volume of 3-cms of tumor.

Example 3: 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 for the 3-cm tumor. When you add up the sizes of the three tumors, report 52240 for private carriers because the sum, volume of tumor adds up to 5 cm.

Example 4: A urologist removes five tumors that are 0.5 cm each from a patient’s bladder. For Medicare, all of the tumors qualify as minor in size, so you should report 52224. But when you add up all five tumors the sum will be 2.5 cm, so you’ll report 52235 for private carriers.

Tip: Double-check with your individual payers to see what their rules are on reporting bladder tumor removals.

Don’t Forget the Modifier Rules

Removing multiple tumors doesn’t allow for an additional code – and you might not be able to include a modifier either.

Explanation: You might be tempted to append modifier 22 (Unusual procedural services) to represent the work of removing more than one tumor because of the additional work involved. You cannot do this, however, because the codes represent the removal of single or multiple lesions as seen by the wording “tumor(s)” or “lesion(s)”

If you’re considering adding modifier 50 (Bilateral procedure) to the claim, verify the payer guidelines in advance. The code descriptors for cystourethroscopic procedures do not indicate that a 50 modifier is appropriate because there is only one midline bladder, but there are two ureters. When the descriptor includes language such as ... “with ureteral catheterization,” you can perform it twice and therefore, can bill it with modifier 50 under CPT^® rules. But remember CPT^® rules are at odds with Medicare rules for some cystourethroscopy procedures.

Separately Report Some Biopsies

Often a urologist will perform a biopsy of a bladder tumor before its complete removal. Your challenge is deciding whether you can separately report the biopsy and the tumor removal procedures during the same encounter.

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, Ferragamo says. 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 treatment which would also include the biopsy of the lesion. Also, the National Correct Coding Initiative (NCCI) bundles 52204 (Cystourethroscopy, with biopsy) into 52224, and you can’t ever use a modifier to bypass this bundling edit.

If the tumor is bigger than 0.5 cm and you report 52234, 52235 or 52240, you can also separately report a bladder biopsy under certain circumstances. If the urologist biopsies normal mucosa (mapping) or a bladder red patch, or a tumor that’s less than 0.5 cm in size and distinct from and in a different bladder location 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.

Pitfall: If your urologist performs a biopsy and a resection of the same lesion, you cannot report a separate service for a biopsy, Medicare says. You should report just the resection (52234-52240).

If there are two different lesions and the smaller lesion is less than 0.5 cm, bill for resection of the larger tumor following the guidelines above. Then, bill for the biopsy of the small lesion using 52204-59. Since NCCI bundles 52204 into 52234, 52235 and 52240, you need modifier 59 to break the bundle.