Wiki 52224 vs 52204

[cheryl.l.smith@medstar.net]

My provider is billing 52224 - but his notes read " 2French rigid cystoscope with blunt obturator was inserted into pts bladder. Complete cystoscopy was then performed. There were multiple posterior bladder lesions all look below 1cm. i inserted cold cup biopsy forceps and biopsied 2 sites noted. All visible lesions were removed with cold cup biopsy forceps. Forceps removed and specimens sent for path analysis. o re-inserted cystoscope and performed Bugbee electrocautery to control bleeding from the biopsied sites."

i removed 52224 and added 52204! am i accurate?

 

[TnRushFan]

It is my understanding that if the entire bladder lesion is removed it is an excisional biopsy - coded to excision.
52234 is for 0.5cm-2cm - per your post he documented "all visible lesions were removed" and they were below 1cm.

 

[cheryl.l.smith@medstar.net]

It is my understanding that if the entire bladder lesion is removed it is an excisional biopsy - coded to excision.
52234 is for 0.5cm-2cm - per your post he documented "all visible lesions were removed" and they were below 1cm.

but he used forceps to remove, 52234 says "remove abnormal tissue by applying an electrical current"

ok fine print!

 

[TnRushFan]

but he used forceps to remove, 52234 says "remove abnormal tissue by applying an electrical current"

ok fine print!
View attachment 6431

By electrical current OR excision...

Just saying I would code it to excision not biopsy.
The pathway in our coding software leads to excision if the entire lesion is removed. The forceps are the tool he used to remove the lesion not the driving factor in his procedure.

"...d. All visible lesions were removed with cold cup biopsy forceps..."

CDR
52234-52240
The physician examines the urinary collecting system with a cystourethroscope passed through the urethra and bladder, and removes tumors of the bladder by electric current (fulguration) or excision. The physician passes an instrument through the endoscope to destroy or remove tumors of the bladder by electric current (fulguration) or excision. The physician may also use liquid nitrogen or carbon dioxide (cryosurgery) or lasers to destroy lesions. The physician removes the instruments and cystourethroscope. For small tumor(s) that are 0.5 up to 2 cm in size, report 52234. For medium bladder tumor(s) that are 2 to 5 cm in size, report 52235. For large tumor(s) that are larger than 5 cm, report 52240.

Excision means "to surgically remove." In medicine, the term indicates the removal of a growth, tissue, organ, or bone using a scalpel, laser, or another cutting tool.

Have a great day, Happy Coding!