Urology Coding Alert
Puzzle Out This Cysto Scenario
Question: The patient had papillary changes of approximately 1 cm to area lateral to left ureteral orifice, which my urologist biopsied and fulgurated. My urologist used the Bugbee electrode to fulgurate the base of the bladder at the biopsy location and the total lesion itself. Excellent hemostasis was achieved. My urologist observed the biopsy site for one minute under low irrigation pressure and no significant bleeding was noted. My urologist removed the cystoscope. Which code should I report for this procedure? AAPC Forum Subscriber Answer: You should report 52234 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)). This is the correct code because your urologist performed a biopsy and then treated the 1 cm lesion with fulguration. So, both the biopsy site and the 1 cm bladder lesion were fulgurated. You should report ICD-10-CM code D49.4 (Neoplasm of unspecified behavior of bladder) on your claim.
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