Urology Coding Alert

Question: Our surgeon took a bladder biopsy using a cystoscope and in the op report described the specimen as “an adherent stone-like structure with calcification affixed to the right lateral bladder wall, measuring 3.4 mm.” The pathology report gives a diagnosis of “transitional cell carcinoma.” What diagnosis and procedure codes should we use?

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Answer: You should code the diagnosis to the highest degree of specificity possible, which means reporting an ICD-10-CM code based on the pathologist’s final diagnosis, not based on the surgeon’s description.

The correct diagnosis code for transitional cell carcinoma of the bladder, also called urothelial carcinoma, is C67- (Malignant neoplasm of bladder).

However, with the anatomic site of the malignancy identified in the surgeon’s preliminary report, you should code the C76 category code to a further degree of specificity. Knowing the malignancy is located on the right lateral bladder wall, your final diagnosis will be C67.2 (Malignant neoplasm of lateral wall of bladder).

For the procedural coding, report 52204 (Cystourethroscopy, with biopsy(s)) for the bladder biopsy.