Part B Insider (Multispecialty) Coding Alert

Published on Sun May 28, 2006 PDF

Learn why tumor size can make all the difference

You could land in coding hot water if you report multiple removal codes for bladder tumors. Use the examples below to choose the right code--for the right situation--every time.

Rule of thumb: Regardless of how many tumors the urologist removes, you should report a single code, says Rhonda Hilton, billing specialist for York County Urology in Biddeford, ME. Rather than adding up the sizes of every tumor the physician removes, choose the code that represents the size of the largest single tumor removed, as Medicare instructs.

Example 1: Your urologist removes a 1-cm tumor and a 5-cm tumor. You’ll use 52240 since the largest tumor fits the large-tumor code description.

Example 2: For another patient, the physician removes three small tumors that he documents as being 1 cm each. Because all of the tumors are the same size, you should use code 52234 in this situation.

Example 3: A patient has three tumors, one of which is 3 cm and two that are 1 cm each. When your urologist removes all three lesions, you should report 52235 for the 3-cm tumor.

Example 4: A urologist removes five tumors that are less than 0.5 cm each from a patient’s bladder. All of the tumors qualify as minor in size, so you should report 52224.

Heads up: When a urologist removes multiple tumors, don’t be tempted to use modifier 22 (Unusual procedural services) or report more than one procedure code. Remember that the CPT Code descriptors for 52224-52240 state “tumor(s)” or “lesions(s),” meaning that each code represents single or multiple tumors of the same size, says Michael Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook.

Pitfall: If your urologist performs a biopsy and a resection of the same lesion, you can’t report a separate service for a biopsy, Medicare says. You should report just the resection (52234-52240).