Urology Coding Alert

Question: We currently have a situation where urine cytology showed cells positive for high grade carcinoma; however, direct tissue biopsy of the bladder revealed no evidence of malignancy (benign). How should we proceed with coding this patient?

Oklahoma Subscriber

Answer: You should use ICD-9 code 791.7 (Other cells and casts in urine) for the positive cytology and 239.4 (Neoplasm of unspecified nature of bladder) for the biopsy before the pathology report is available.

Use 791.7 for the E/M visit and 239.4 for the biopsy (52204). You may also use the diagnosis for a benign bladder lesion 223.3 (Benign neoplasm of bladder) once the “non-malignant, benign” pathology report is known.

ICD-10 Note: When ICD-10 goes into effect on October 1, 2014, you’ll use the following:

• R82.8 (Abnormal findings on cytological and histological examination of urine) instead of 791.7
• D49.4 (Neoplasm of unspecified behavior of bladder) instead of 239.4
• D30.3 (Benign neoplasm of bladder) instead of 223.3.