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 base my coding on comments from the doctor such as ‘medium tumor.’ 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: When the urologist fails to record the size of a bladder tumor resected, in most situations, you can – and should – bill based on the tumor size documented in the pathology report. The exceptions are when you have a specific payer telling you in writing that you should not estimate the tumor size from the pathology report when your urologist has not provided this information to you. However, be aware that billing based on the size reported in the pathology report may lead to inaccurate coding and decreased reimbursements because of shrinkage of the specimen in the fixation solution.

Explanation: Your doctor should be documenting the size of the tumor in his operative reportusing either a specific measurement or terms such as “minor,” “small,” “medium,” or “large.” If he does not provide you with this information, coding principles direct you 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. However, you may base your ICD-10 code on the diagnosis given by the experienced urologist’s visual cystoscopic findings of a malignant tumor.

Instead of waiting for the path report, you can, however, use D49.4 (Neoplasm of unspecified behavior of bladder) as a payable diagnostic code when initially submitting the claim before a pathological diagnosis is known.