Urology Coding Alert

Question: Our doctor performed a cystoscopy with clot evacuation, tumor fulguration, and bladder biopsies. I checked to see what I could and could not bill together and between the doctor and myself, we came up with this:

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Answer: Your problem could be one of two things: First, and probably most likely -- you need to attach  modifier 59 (Distinct procedural service) to 52001 (Cystourethroscopy with irrigation and evacuation of multiple obstructing clots) for the cystoscopic evacuation of the multiple obstructing bladder clots. The Correct Coding Initiative (CCI) edits bundle 52001 into 52204 (Cystourethroscopy, with biopsy[s]). This bundle has a modifier indicator of 1, so if clinical circumstances warrant, you can break this bundle, but to do so you must add modifier 59 to 52001.

Alternative: The second possibility is an incorrect diagnostic code. Codes 599.71 (Gross hematuria) and V10.51 (Personal history of malignant neoplasm;; urinary organs; bladder) are probably not your best diagnosis choices.

The diagnosis for the cystoscopy and clot evacuation should probably be clot retention if the patient had  multiple obstructing clots. Therefore, use 596.8 (Otherspecified disorders of the bladder) for clot urinary retention. Use bladder tumor code 188.4 (Malignant neoplasm of bladder; posterior wall of urinary bladder) or the "pathology pending" diagnosis code (239.4, Neoplasms of unspecified nature; bladder) for 52204.

Important: In this case, the payer paid for 52204. In the future, however, you may want to consider 52224 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] or treatment of MINOR [less than 0.5 cm] lesion[s] with or without biopsy) -- or 52234 (... and/or resection of; SMALL bladder tumor[s] [0.5 up to 2.0 cm]), 52235 (... MEDIUM bladder tumor[s] [2.0 to 5.0 cm]), or 52240 (... LARGE bladder tumor[s]), depending on tumor size documented -- if your urologist used the biopsy and fulguration to actually treat the bladder tumor. (Remember that if the urologist doesn't document the size of the tumor, you must assume the smallest size when choosing the proper CPT code for the tumor removal.)

If your urologist did a biopsy and fulgurated a resulting bleeder at the biopsy site without treatment (removal) of a lesion, you should report only 52204, as this code includes biopsy as well as the fulguration of a bleeder. On the other hand, if the urologist is "treating" a small lesion less than 0.5 cm in size with biopsy and complete fulguration, code 52224. In other words, if the physician biopsied a minor lesion and then fulgurated its base or any remaining part of the lesion, use 52224.

In that case your coding would likely have been:

• 52001-59 Dx. 596.8

• 52224 Dx. 188.4 or 239.4.

Note: Because CPT code 52001 has more relative value units (RVUs) than 52224 or 52204, bill 52001 as the primary procedure even though CCI bundles 52204 and 52224. Append modifier 59 to 52001 to bypass this edit. The latter procedures represent the secondary procedures and you bill those second.