Urology Coding Alert

Question: My urologist performed a cystoscopy, transurethral resection of bladder tumors with fulguration. The patient has a history of bladder cancer with bladder tumors. Per the medical documentation, the patient was brought to the operating room (OR) after the anesthesiologist administered anesthesia. My urologist put the patient in dorsal lithotomy position and prepped and draped in usual sterile fashion. Using a 21-French cystoscope sheath, my urologist entered the bladder via the urethra. They examined the bladder with 30- and 70-degree lenses. The patient had a papillary tumor at the bladder neck and around the right ureteral orifice and almost completely in different spots around the bladder neck. My urologist removed the cystoscope sheath. They used a 25-French resectoscope with an obturator to enter in the bladder via the urethra using a standard electrode loop. They then resected the right bladder neck superficial and deep, floor superficial and deep, the right ureteral orifice, left bladder neck and then cauterized any small tumors and mucosal abnormalities around the bladder neck. After all the tumors had been Elliked out and my urologist had good hemostasis, they removed the resectoscope. They then inserted a 22-French 3-way Foley catheter in the bladder via the urethra. The balloon was inflated with 15 mL of sterile water. The patient was taken down out of dorsal lithotomy position, extubated, and taken to the recovery room in stable condition. Which codes should I report for this procedure?

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Answer: You should look at codes 52234 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/ or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm))-52240 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s)). However, you need to know the size of the tumors to choose the appropriate code. For multiple bladder tumors resected/treated at the same encounter, most carriers will require one to code for the largest tumor resected, which will also include the removal of the multiple smaller tumors.

You should report C67.5 (Malignant neoplasm of bladder neck) for the ICD-10-CM code. Code C67.5 also includes malignant neoplasm of internal urethral orifice.