Urology Coding Alert

Question: The urologist's documentation states there was a 2.5 cm papillary lesion in the distal part of the prostate. Using a resectoscope, he resected the area of the prostate including the lesion. What would be the correct CPT code to use in this situation?

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Answer: Report 52235 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; MEDIUM bladder tumor[s] [2.0 to 5.0 cm]) for this resection of a tumor in the prostatic urethra. Because CPT lists the transurethral resection of bladder tumor (TURBT) codes under the heading of bladder and urethra, you can use the standard TURB codes for this lesion.

Diagnosis help: For an ICD-9 code, use 239.5 (Neoplasms of unspecified nature; other genitourinary organs) to indicate the pending pathology for the lesion in the urinary tract. Or if your urologist is highly suspicious that this is a low-grade malignancy, then use 189.3 (Malignant neoplasm of kidney and other and unspecified urinary organs: urethra). If the lesion turns out to be a prostatic urethral polyp composed of benign prostate tissue, use 600.20 (Benign localized hyperplasia of prostate without urinary obstruction and other lower urinary tract symptoms [LUTS]).

-- Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook.