Urology Coding Alert

Reader Question:

Code TURBT From Op Report, Not Path Report

Question: I have a question regarding TURBT. I have been told that I can no longer get the size of the tumor from the path report or if the doctor says medium tumor, I can't use that. They said that the doctor has to state the size of the tumor in the report in order for me to code it, and if he doesn't, I have to have them do an addendum or code to the smallest size. Is this correct?Indiana SubscriberAnswer: Unless you have a specific payer telling you in writing that you should not estimate the tumor size from the pathology report, and your urologist has not provided this information to you, you can and should bill 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 doctor [...]
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