Urology Coding Alert

Question: The urologist performed a resection of a bladder neck tumor, as well as a resection of papillary fronds on the right prostatic fossa. The patient also had evidence of prior TURP. Since the tumor isn’t really within the bladder, I’m hesitant to use codes CPT 52500 and 52630. Would they be appropriate?


Florida Subscriber


Answer: You should report CPT 52234 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; SMALL bladder tumor[s]), 52235 (… MEDIUM bladder tumor[s]), or 52240 (… LARGE bladder tumor[s]) depending on the size of the tumor. A small tumor ranges from 0.5 up to 2.0 cm, a medium tumor ranges from 2.0 to 5.0 cm, and a large tumor is 5.0 cm or larger, according to the CPT Code descriptions.

Remember that the patient has had a previous transurethral resection of the prostate. In these cases, you should consider the bladder cavity and the opened resected prostatic urethra to be one cavity. In fact, the resected prostatic fossa postoperatively is epithelialized mostly with transitional mucosa from the bladder.

Therefore, you should code the bladder tumor resections as you would code if the tumors were confined to the bladder alone. In the scenario you provide, the urologist may have seen multiple bladder tumors. For Medicare, code only for the largest tumor resected. For private or commercial carriers, code for the total volume of tumor resected.