Urology Coding Alert

Learn why you can't report more then one code using modifier 22

You may think it's logical that if your urologist removes more than one bladder tumor you should base your coding on the size and number of tumors. But logical or not, Medicare makes it clear that you're not coding correctly if you report more than one removal code or add up the sizes of the individual tumors.

Know Your Options

When your urologist transurethrally removes tumors from a patient's bladder, you have several codes to choose from to report the procedure. The first step in choosing which code you report depends on the size of the tumor or tumors, as the code descriptors indicate.

Your urologist will make a visual estimate of the size of a bladder tumor during a cystourethroscopy procedure. Based on the size estimate he documents in the operative report, you'll select one of four codes:
 
• Use CPT 52224 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] or treatment of MINOR [less than 0.5 cm] lesion[s] with or without biopsy) for less than 0.5 cm.

• Use CPT 52234 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; SMALL bladder tumor[s] [0.5 up to 2.0 cm]) for 0.5 to 2.0 cm.

• Use 52235 (... MEDIUM bladder tumor[s] [2.0 to 5.0 cm]) for 2.0 to 5.0 cm.

• Use 52240 (... LARGE bladder tumor[s]) for 5.0 cm or more.

Size Is All that Matters With Removal

Regardless of how many tumors the urologist removes, you should report a single code, says Rhonda Hilton, billing specialist for York County Urology in Biddeford, Maine. For Medicare, you should not add up the sizes of every tumor the physician removes. Instead, choose the code that represents the size of the largest single tumor removed.

For private payers, you should add up the sizes of all the tumors and choose your code based on the sum, says Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook.

Example 1: Your urologist removes a 1-cm tumor and a 5-cm tumor. For Medicare, you'll use 52240 since the largest tumor fits the large-tumor code description. For private carriers, you'll still report 52240 since the tumor sizes add up to 6 cm.

Example 2: For another patient, the physician removes three small tumors that he documents as being 1 cm each. Because all of the tumors are the same size, you should use code 52234 in this situation for Medicare. For private payers, add up all the tumors and you get 3 cm. This means you'll use 52235 for non-Medicare carriers.

Example 3: A patient has three tumors, one of which is 3 cm and two that are 1 cm each. When your urologist removes all three lesions, you should report 52235 to Medicare for the 3-cm tumor. When you add up the sizes of the three tumors, you'll discover that you should report 52240 to private carriers because they add up to 5 cm.

Example 4: A urologist removes five tumors that are less than 0.5 cm each from a patient's bladder. For Medicare, all of the tumors qualify as minor in size, so you should report 52224. But when you add up all five tumors the sum will be more than 0.5, so you'll report 52234 to private carriers.

Tip: Double-check with your individual payers to see what their rules are on reporting bladder tumor removals.

Don't Be Tempted to Apply a Modifier

When a urologist removes multiple tumors, don't be tempted into using modifier 22 (Unusual procedural services) or reporting more than one procedure code. You may consider this option because the physician does more work removing multiple tumors than he does when he removes just one.

The problem is that the CPT code descriptors for 52224-52240 state "tumor(s)" or "lesions(s)," meaning that each code represents single or multiple tumors of the same size, Ferragamo says.

Separately Report Some Biopsies

Often a urologist will perform a biopsy of a bladder tumor before its complete removal. Your challenge is deciding whether you can separately report the biopsy and the tumor removal procedures during the same encounter.

Code 52224 specifies "with or without biopsy," so if your urologist performs a biopsy before removing a tumor that is smaller than 0.5 cm, you cannot report both services, Ferragamo says. In this case, because of the small size of the tumor, a biopsy often removes the tumor completely, and therefore you should only report code 52224 for treatment and the biopsy of the lesion. Also, the National Correct Coding Initiative (NCCI) bundles 52204 (Cystourethroscopy, with biopsy) into 52224, and you can't ever use a modifier to bypass this bundling edit.

If the tumor is bigger than 0.5 cm and you report 52234, 52235 or 52240, you can also separately report a bladder biopsy under certain circumstances. If the urologist biopsies normal mucosa (mapping) or a bladder red patch, or a tumor that's less than 0.5 cm in size and distinct from and in a different bladder location from the initial tumor, report the biopsy separately. Use 52204 and append modifier 59 (Distinct procedural service) to indicate that the biopsy was a separate procedure.

Pitfall: If your urologist performs a biopsy and a resection of the same lesion, you can't report a separate service for a biopsy, Medicare says. You should report just the resection (52234-52240).

If there are two different lesions and the smaller lesion is less than 0.5 cm, bill for resection of the larger tumor following the guidelines above. Then, bill for the biopsy of the small lesion using 52204-59. Since NCCI bundles 52204 into 52234, 52235 and 52240, you need modifier 59 to break the bundle.