Urology Coding Alert

Question: The urologist performed cystoscopy to diagnose bladder cancer and right hydronephrosis. Some unresected anterior dome bladder wall tumor papillary could not be completely resected. He also was unable to locate the right ureteral orifice to place a stent for the right hydroureteronephrosis. No dye came out of the right ureteral orifice. The area was already thin from a prior TURBT. The urologist did no further resection in order to avoid bladder perforation. The tissue medial to that area was resected minimally to remove the “fluff” burnt tissue from the prior resection. How do I code all of this?

Virginia Subscriber

Answer: The correct answer and diagnosis depends on whether the pathology report showed that the resected medial tissue was a tumor. If it was, you should report the procedure based on the size of the tumor resection with the diagnosis C67.6 (Malignant neoplasm of ureteric orifice).

Your procedure code options are:

• 52234 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) 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))
• 52240 (… LARGE bladder tumor(s)).

If the resected tissue is not a tumor, then report one of the above procedures with the ICD-10-CM diagnostic codes C67.6, the clinical reason for the procedure, and ICD-10-CM code Z71.1 (Person with feared health complaint in whom no diagnosis is made) for the negative findings.

An alternative method of coding for this scenario may include procedure code 53899 (Unlisted procedure, urinary system), as there is no specific code defining the procedure performed that revealed no residual tumor.

Remember:  When reporting a procedure with an unlisted code, submit a cover letter explaining the reason for choosing the unlisted code instead of a defined, active code. Include one or more similar codes and compare your service to those codes to justify the claim amount you are billing. Also include the operative notes or other relevant documentation to strengthen the claim and to avoid a possible denial.