Urology Coding Alert

Question: How should I code for "random biopsies" in the bladder?

Texas Subscriber

Answer: A random biopsy is performed when the urologist wants to see if cancer exists in different areas. Usually, the patient has a pre-existing diagnosis of carcinoma in situ. You should use 52204 (Cystourethro-scopy, with biopsy) for the initial biopsy and 52204 with modifier -59 (Distinct procedural service) for all subsequent biopsies. For Medicare, each biopsy should have a separate line. Some private carriers request 52204 on the first line and 52204-59 with the number of biopsies obtained in the units column on the second line.

Medicare and other carriers may not reimburse for every biopsy performed. In New York, Medicare has reimbursed for up to four biopsies. If the biopsies are performed in the hospital, payments vary from $15 to $35 per biopsy after the initial biopsy. Office biopsies will pay more because of the increased office expense.

You should link the diagnosis code for the cancer, or, if there is no previously diagnosed cancer use 239.4 (Neoplasms of unspecified nature; bladder). If the previous biopsy was inconclusive, report 236.7 (Neoplasm of uncertain behavior of genitourinary organs; bladder).