Urology Coding Alert

Answer: ICD-10-CM includes numerous diagnoses for malignant neoplasm of the bladder. You will be able to pinpoint the correct code once you know the exact site of the tumor. Your code choices are as follows:

• C67.0 (Malignant neoplasm of trigone of bladder)
• C67.1 (Malignant neoplasm of dome of bladder)
• C67.2 (Malignant neoplasm of lateral wall of bladder)
• C67.3 (Malignant neoplasm of anterior wall of bladder)
• C67.4 (Malignant neoplasm of posterior wall of bladder)
• C67.5 (Malignant neoplasm of bladder neck)
• C67.6 (Malignant neoplasm of ureteric orifice)
• C67.7 (Malignant neoplasm of urachus)
• C67.8 (Malignant neoplasm of overlapping sites of bladder)
• C67.9 (Malignant neoplasm of bladder, unspecified)

Report C67.8 in This Case

FAQ 2: I am new to coding, and I’m not sure when to report code C67.8. Can you help me?

Answer: Code C67.8 is used when the patient has a primary malignant neoplasm that overlaps two or more contiguous (side-by-side) sites in the bladder. If a bladder tumor on the trigone also extends and involves the posterior bladder wall, diagnosis C67.8 would be appropriate.

Turn to This Code for Benign Bladder Neoplasm

FAQ 3: What ICD-10-CM code should I report if the pathology report shows that the bladder neoplasm is benign?

Answer: If the pathology report shows a bladder neoplasm is benign, you should report D30.3 (Benign neoplasm of bladder). Coding notes explain that D30.3 also includes benign neoplasm of both the ureteric orifice and urethral orifice of the bladder.

Discover Bladder Biopsy Reporting

FAQ 4: My urologist performed a bladder biopsy to rule out a cancer diagnosis. They used cold cup biopsy forceps to obtain tissue without cautery for pathology. This was sent off for permanent section as posterior wall. Additional cold cup biopsies were taken of the left and right trigone and sent off separately for permanent pathology. Which CPT^® code should I report?

Answer: Since your urologist only performed biopsies, not fulguration or destruction, you should report 52204 (Cystourethroscopy, with biopsy(s)).

Urologist Documented Transitional Cell Carcinoma? Do This

FAQ 5: My urologist took a bladder biopsy using a cystoscope. In the op report, they described the specimen as “an adherent stone-like structure with calcification affixed to the right lateral bladder wall, measuring 3.4 mm.” The pathology report gives a diagnosis of “transitional cell carcinoma.” What diagnosis and procedure codes should I report?

Answer: You should code the diagnosis to the highest degree of specificity possible, which means reporting an ICD-10-CM code based on the pathologist’s final diagnosis, not based on the surgeon’s description.

The correct diagnosis code for transitional cell carcinoma of the bladder, also called urothelial carcinoma, is C67- (Malignant neoplasm of bladder).

Although you should not report the surgeon’s less-specific findings using a code such as D49.4 (Neoplasm of unspecified behavior of bladder), you do need to use the surgeon’s identification of the tumor anatomic site to assign the most specific ICD-10 code. The final diagnosis for this case should be C67.2 (Malignant neoplasm of lateral wall of bladder). However, when you are waiting for a pathology report of a bladder lesion biopsy, you may report D49.4 (Neoplasm of unspecified behavior of bladder) to indicate “path pending,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook.

The appropriate procedure code for this case is 52204 (Cystourethroscopy, with biopsy(s)).