Urology Coding Alert

When urologists remove more than one bladder tumor, selecting a code or codes based on the size and number of tumors may seem reasonable. It is not, however, correct coding. CPT lacks clarity in describing bladder lesion removal (52224-52240), but Medicare is clear: Bill only one tumor removal code. Urologists need to know the national rules set by Medicare, as well as individual private-payer rules, to maximize ethical reimbursement for these procedures.
 
Tumor size is based on a visual estimate of tumor at cystoscopy. Select the tumor removal code based on this estimate. Use 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, 52234 (cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; SMALL bladder tumor[s] [0.5 to 2.0 cm]) for 0.5 to 2.0 cm, 52235 ( MEDIUM bladder tumor[s] [2.0 to 5.0 cm]) for 2.0 to 5.0 cm, and 52240 ( LARGE bladder tumor[s]) for 5.0 cm or more. Use 52204 (cystourethroscopy, with biopsy) for a biopsy of any size tumor.
Select Code Based on Size
For Medicare, bill the single code for the largest single tumor removed, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding consultancy based in Denver. For private payers, add up, or aggregate, the tumor sizes and bill the code for the aggregate size.
 
For example, the urologist removes a 1-cm tumor and a 5-cm tumor. For Medicare, code for the largest tumor removed: 52240. For private payers, add the tumor mass (1 cm and 5 cm) and use 52240.
 
In another example, the urologist removes three small tumors (1 cm each). For Medicare, bill only the code for the single largest tumor (1 cm): 52234. For private payers, add the tumor mass (3 cm) and use 52235.
 
In a third example, the urologist removes two small tumors (1.5 cm each) and one medium tumor (2 cm). For Medicare, code 52235. For private payers, add up the tumor mass (5 cm) and code 52240.
 
In a fourth example, the urologist removes five minor tumors (smaller than 0.5 cm each). For Medicare, code 52224. For private payers, add up the tumor mass (it will be more than 0.5 cm) and code 52234.

Modifier -22 Is Not Recommended
Some urologists might be tempted to use modifier -22 (unusual procedural services) when billing multiple tumor removal. Because it's more work to remove three tumors than one, they think modifier -22 is warranted. But this is controversial because CPT implies that each tumor removal code is for one or more tumors. Page doesn't recommend billing multiple tumor removals with modifier -22 simply to indicate multiplicity.
Diffuse Area of Tumor
In a [...]