Urology Coding Alert
Dive Into This Bladder Tumor Scar Scenario
Question: The patient is here for a follow-up transurethral resection of a bladder tumor (TURBT) due to a high likelihood of having stage 1 urothelial cell carcinoma, as per the guidelines set by the American Urological Association (AUA). The observations revealed a medium-sized scar, measuring over 2 cm, located on the left side of the bladder wall. The scar was in close proximity to the left ureteral orifice; however, it did not affect 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. How should I code this? Tennessee Subscriber 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 code would be D49.4 (Neoplasm of unspecified behavior of bladder), path pending. Make sure there is specific documentation of the size of the suspected tumor removed. 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).
Urology Coding Alert
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