Urology Coding Alert

Check your complicated case savvy against the advice from the experts.

It's not uncommon for your urologist to remove a patient's bladder tumor. Be sure you're in-the-know next time you're faced with one of these claims by brushing up on five key points.

Key Point 1: Don't Add Tumor Sizes For Medicare

When filing Medicare claims, with multiple bladder tumors, do not add up the sizes of every tumor the physician removes. Instead, choose the code that represents the size of the largest single tumor resected, says Becky Boone, CPC, CUC, CPMA,  senior urology coder for The Coding Network, LLC. Choose the procedure code that fits the largest tumor size.

Pay attention: Some private payers, though not all, will allow you to add up the tumors when selecting the code. Therefore, for some private payers, you should add up the sizes of all the tumors and choose your code based on this sum or volume of tumor removed. For example, if the urologist removes two tumors that are 1.5 cm and 2 cm, you could report 52235 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; medium bladder tumor[s], [2.0 to 5.0 cm]) for a medium-sized tumor.

Tip: Commercial payers will pay differently, but more will follow the standard Medicare guidelines. 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.

Key Point 2: Large and Small Tumors Could Mean 2 Codes

When you're billing Medicare or private carriers for the resection (removal) of a bladder tumor 3.5 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 3.5 cm bladder tumor, and
• 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 the minor tumor resection. Add modifier 59 (Distinct procedural service) to 52224 to bypass the edits bundling 52224 with the other bladder tumor resection codes.

Key Point 3: Skip Modifier 22 For Multiple Tumors

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. However, this approach is incorrect.

Reasoning:  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 of the same size.

Remember: 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. "Remember to not add the modifiers if your documentation does not back it up," Hines warns.

Key Point 4: Determine if You Can Count Bladder Biopsy with Tumor Resection Code

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

Warning: 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 should not 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, Boone explains. The Correct Coding Initiative (CCI) reinforces this by bundling 52204 (Cystourethroscopy, with biopsy[s]) into 52224, and you can never use a modifier to bypass this bundling edit.

Silver lining: If the tumor is larger 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 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 or modifier XU (Unusual non-overlapping service) (according to the AUA Policy and Advocacy Brief, June 2016) 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 or XU since they have a modifier indicator of '1,'" Boone explains.

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).

Key Point 5: Insist Urologist Documents Tumor Size

If your urologist does not document the size of the tumor in his surgical report, you have two choices: report 52224 or wait for the pathology report to come back and then use the size documented in that report.

Best bet: If your urologist has not provided this information to you, you should bill based on the tumor size reported in the pathology report. However, billing based on the size reported in the pathology report may lead to inaccurate coding and decreased reimbursements.

Here's why: Your urologist should be documenting the size of the tumor in his operative report-- using either a specific measurement or terms such as "minor," "small," "medium," or "large." If he does not provide you with this information, you are mandated by coding principles to report the code for the smallest size tumor or code from the path report. However, once the specimen is placed in formalin preserving solution, the specimen will shrink to a much smaller size, sometimes half its original size. Therefore, when coding for this smaller specimen size, you will likely be coding lower and getting paid less than if your doctor had documented the actual tumor size seen at surgery.

Final note: Experts say that physicians must back up the rules for these bladder tumors by documenting in the chart, the op notes, or making sure the proper size(s) are picked on the EMR. Quite a bit of revenue can be lost by wanting to fight for what a physician actually did when the specific size is not documented.