Urology Coding Alert

Question: What code would be best for resection of a tumor in the urethra? The doctor used a resectoscope to remove the tumor from the urethra during the same session as a cystoscopy.

Wisconsin Subscriber

Answer: The correct code for tumor resection/removal will be based on the tumor's size documented in the operative report. Your options are:

• 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).

The above CPT^® codes are listed in the 2018 CPT^® Manual under the heading Transurethral Surgery, Urethra and Bladder; therefore, you can use these codes for treatment of both urethral or bladder pathology. Most urethral tumors are small when discovered, and codes 52224 or 52234 are most often used to describe the resections performed.