Urology Coding Alert

Learn why you can't report more then one code using modifier 22

You may think it's logical that if your urologist removes more than one bladder tumor you should base your coding on the size and number of tumors. But logical or not, Medicare makes it clear that you're not coding correctly if you report more than one removal code or add up the sizes of the individual tumors. Know Your Options When your urologist transurethrally removes tumors from a patient's bladder, you have several codes to choose from to report the procedure. The first step in choosing which code you report depends on the size of the tumor or tumors, as the code descriptors indicate.

Your urologist will make a visual estimate of the size of a bladder tumor during a cystourethroscopy procedure. Based on the size estimate he documents in the operative report, you'll select one of four codes:
 
• Use CPT 52224 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] or treatment of MINOR [less than 0.5 cm] lesion[s] with or without biopsy) for less than 0.5 cm.

• Use CPT 52234 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; SMALL bladder tumor[s] [0.5 up to 2.0 cm]) for 0.5 to 2.0 cm.

• Use 52235 (... MEDIUM bladder tumor[s] [2.0 to 5.0 cm]) for 2.0 to 5.0 cm.

• Use 52240 (... LARGE bladder tumor[s]) for 5.0 cm or more. Size Is All that Matters With Removal 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, Maine. For Medicare, you should not add up the sizes of every tumor the physician removes. Instead, choose the code that represents the size of the largest single tumor removed.

For private payers, you should add up the sizes of all the tumors and choose your code based on the sum, says Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook.

Example 1: Your urologist removes a 1-cm tumor and a 5-cm tumor. For Medicare, you'll use 52240 since the largest tumor fits the large-tumor code description. For private carriers, you'll still report 52240 since the tumor sizes add up to 6 cm.

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 for Medicare. For private payers, add up all the tumors and you get 3 cm. This means you'll use 52235 for non-Medicare carriers.

Example 3: A patient has three tumors, one of which is 3 cm and two that [...]