Urology Coding Alert

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 Subscriber

Answer: 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 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.

How it works: Based on the size estimate your urologist documents in the operative report, you'll select one of four codes:

• Use 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 less than 0.5 cm.
• Use 52234 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; SMALL bladder tumor[s] [0.5 up to 2.0 cm]) for 0.5 to 2.0 cm.
• Use 52235 (... MEDIUM bladder tumor[s] [2.0 to 5.0 cm]) for 2.0 to 5.0 cm.
• Use 52240 (... LARGE bladder tumor[s]) for 5.0 cm or more.

Important: You do need the pathology report to eventually choose a diagnosis code, but not for the size of the tumor. You should always choose the malignant or benign diagnosis code based on the results of the pathology report even if the physician did not know at the excision time that the tumor was malignant. The pathology report offers the definitive diagnosis. Although on cystoscopic examination an experienced urologist is often able to visually identify a tumor as benign or malignant, you may still want to code the diagnosis based on the pathology report.

Instead of waiting for the path report, you can, however, use 239.4 (Pathology pending, bladder tumor) as a payable diagnostic code when initially submitting the claim before a pathological diagnosis is known.