Urology Coding Alert

Question: The urologist completed a cystourethroscopy with two lesions removed from different locations in the patient's bladder. One lesion was 1.6 cm bladder tumor of the lateral wall. The other was 0.9 cm in the anterior wall. What coding rule applies?

South Carolina Subscriber

Answer: For Medicare carriers, code the encounter based on the size of the largest tumor resected. In the scenario you describe, you would report 52234 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; SMALL bladder tumor[s] [0.5 up to 2.0 cm]). Notice that the descriptor includes both the cysto and the lesion removal, which is why you don't report both procedures separately.

For non-Medicare payers, code the resection code based on the volume of bladder tumor removed. For this patient on a non-Medicare insurance plan, bill code 52235 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; MEDIUM bladder tumor[s] [2.0 to 5.0 cm]).