Urology Coding Alert

Question: My surgeon performed a transurethral resection of bladder tumor (TURBT). The resection method states cold cups; however, my surgeon gave the tumor dimensions as well, measuring 3-5 cm. Would I report 52204 since the cold cups were used as the resection method?

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Answer: In this case, you should not report 52204 (Cystourethroscopy, with biopsy(s)).

Instead, report 52235 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; medium bladder tumor(s) (2.0 to 5.0 cm)) since there was a resection, based on the tumor size your urologist documented.