Urology Coding Alert

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

Find out if you're set to properly code your urologist's bladder tumor removal procedures by checking your answers to the five quiz questions on page 75 against this answer key.

Answer 1: Avoid Adding Up Tumor Sizes For Medicare

For Medicare, you'll report CPT 52235 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; medium bladder tumor[s], 2.0 to 5.0 cm) for this case since the largest tumor fits the medium-tumor code description. You should not add up the sizes of every tumor the physician removes when billing Medicare. Instead, choose the code that represents the size of the largest single tumor resected, says Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia.

Some private carriers, though not all, will allow you to add up the tumors. 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. In this case, if you were reporting the removals to a private payer instead of Medicare you would report 52240 (... Large tumor) since the tumor sizes add up to 5 cm.

Tip: "It is true that commercial payers will pay differently, but ... more will follow the standard Medicare guidelines," says Chandra L. Hines, business office manager at Capital Urological Associates in Raleigh, N.C. 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.

Answer 2: 3.5 cm Tumor + Second Minor Tumor Means 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.

Answer 3: Skip Modifier 22 For Multiple Tumors

For Medicare, bill 52234 (...SMALL bladder tumor[s] [0.5 up to 2.0 cm]) for the resection of a 1 cm tumor, the largest tumor present. On the other hand, for private payers, add up the sizes of the tumors and bill 52240 based on the sum or volume of all tumors removed, or 5 cm.

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.

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.

Answer 4: Count Biopsy in Tumor Removal Code -- Sometimes

If your urologist performs a bladder biopsy before removing a bladder tumor, under certain circumstances, 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 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 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).

Answer 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 using 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.

"Physicians must back up the rules for these bladder tumor by documenting in the chart, the op notes, or making sure the proper size(s) are picked on the EMR," Hines says. "Quite a bit of revenue can be lost by wanting to fight for what a physician does but the specific size is not documented."