Urology Coding Alert

Question: This patient is at high risk for stage 1 urothelial cell carcinoma and is here for restaging transurethral resection of a bladder tumor (TURBT), based on the American Urological Association’s (AUA) guidelines. The findings included a medium-sized scar over 2 cm in size present at the left lateral bladder wall. The scar was abutting the left ureteral orifice but not involving it. My urologist did not see an obvious tumor, but the previous resection could be distorting it. My urologist performed resection of the bladder tumor scar, and the bladder tumor chips were sent to the lab. The pathology came back as granulation tissue, benign bladder wall with acute and chronic inflammation. There was no evidence of malignancy. My colleague said we should report 52235 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/ or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm)) but I don’t think this is the correct option since no actual tumor was found as it had been previously removed. Can you help me?

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Answer: Your urologist performed the resection because more tumors were suspected. You should report the TURBT code 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 clinical scenario. Your ICD-10-CM code would be D49.4 (Neoplasm of unspecified behavior of bladder), path pending.

For the follow-up visit, since no recurrent tumor was found, you can look to Z71.1 (Person with feared health complaint in whom no diagnosis is made).