Urology Coding Alert

Question: I need a clarification on when to use a history of bladder cancer versus bladder tumor of unspecified nature (239.4). I understand once a patient no longer has the cancer and is no longer receiving treatment we move to the history code. But someone told me that “when a patient has been diagnosed with bladder cancer, the protocol is cystoscopy every three months for a couple of years, then every six months, and last every year. All along the patient is being monitored, and the bladder cancer code should still be used until the patient is in the yearly cystoscopy stage.” This isn’t how I thought it was supposed to work.

What if a patient returns for a six month surveillance cystoscopy, and a recurrent bladder tumor is found? There isn’t a pathology report yet so we do not know if it is malignant. Do we only use 239.4 or both 239.4 and V10.51?

Oregon Member

Answer: You should use both V10.51 (Personal history of malignant neoplasm of bladder) for the medical reason or necessity for performing the cystoscopic examination, and 239.4 (Neoplasm of unspecified nature of bladder) for an E/M service billed on face to face time during which your physician counsels the patient and coordinates his future care including preoperative evaluation and type of surgical care necessary to treat the newly discovered bladder tumor. 

You should also attach modifier 25 (Significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code for payment of this counseling and the coordination of care.

Remember: You should only use the V10.51 code, when there is no clinical, endoscopic, or laboratory evidence of bladder tumor and when you are no longer providing active treatment of the tumor. Basing your diagnosis code on the time frame of a cystoscopic examination is not correct coding.