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Urology Coding Alert

Select Codes for Bladder Tumor Removal by Size, Not Number

Published on Tue Jan 01, 2002

When urologists remove more than one bladder tumor, selecting a code or codes based on the size and number of tumors may seem reasonable. It is not, however, correct coding. CPT lacks clarity in describing bladder lesion removal (52224-52240), but Medicare is clear: Bill only one tumor removal code. Urologists need to know the national rules set by Medicare, as well as individual private-payer rules, to maximize ethical reimbursement for these procedures.
 
Tumor size is based on a visual estimate of tumor at cystoscopy. Select the tumor removal code based on this estimate. Use 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, 52234 (cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; SMALL bladder tumor[s] [0.5 to 2.0 cm]) for 0.5 to 2.0 cm, 52235 ( MEDIUM bladder tumor[s] [2.0 to 5.0 cm]) for 2.0 to 5.0 cm, and 52240 ( LARGE bladder tumor[s]) for 5.0 cm or more. Use 52204 (cystourethroscopy, with biopsy) for a biopsy of any size tumor.

Select Code Based on Size

For Medicare, bill the single code for the largest single tumor removed, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding consultancy based in Denver. For private payers, add up, or aggregate, the tumor sizes and bill the code for the aggregate size.
 
For example, the urologist removes a 1-cm tumor and a 5-cm tumor. For Medicare, code for the largest tumor removed: 52240. For private payers, add the tumor mass (1 cm and 5 cm) and use 52240.
 
In another example, the urologist removes three small tumors (1 cm each). For Medicare, bill only the code for the single largest tumor (1 cm): 52234. For private payers, add the tumor mass (3 cm) and use 52235.
 
In a third example, the urologist removes two small tumors (1.5 cm each) and one medium tumor (2 cm). For Medicare, code 52235. For private payers, add up the tumor mass (5 cm) and code 52240.
 
In a fourth example, the urologist removes five minor tumors (smaller than 0.5 cm each). For Medicare, code 52224. For private payers, add up the tumor mass (it will be more than 0.5 cm) and code 52234.

Modifier -22 Is Not Recommended

Some urologists might be tempted to use modifier -22 (unusual procedural services) when billing multiple tumor removal. Because it's more work to remove three tumors than one, they think modifier -22 is warranted. But this is controversial because CPT implies that each tumor removal code is for one or more tumors. Page doesn't recommend billing multiple tumor removals with modifier -22 simply to indicate multiplicity.

Diffuse Area of Tumor

In a special case, an operative note may refer to a diffuse area of tumor formation or carcinoma in situ (CIS), and refer to this as an aggregate area. For example, the urologist fulgurates and resects a 6-cm area of carcinoma in situ, 52240.
 
If the urologist removes a diffuse area of confluent tumor or CIS formation select the code based on the amount of space fulgurated and resected "" says Michael Ferragamo MD professor of urology at the State University of New York Stony Brook.

Billing for Biopsies

If during a biopsy the urologist removes the entire lesion (smaller than 0.5 cm) bill based on the size of the lesion removed with 52224. Otherwise bill 52204 for a biopsy.
 
If a biopsy (52204) is performed at the time of the surgery and a resection of the same lesion is also done don't charge separately. Bill only for the resection (52234-52240 depending on the size of the lesion).
 
Medicare says a separate service can't be reported for a biopsy and an excision of the same lesion. If there are different lesions however the urologist can bill using modifier -59 (distinct procedural service). For example the urologist biopsies one lesion and excises another. Bill one bladder tumor removal (52224-52240) for the lesion removal and 52204-59 for the biopsy.
 
Another example is when the urologist removes a 3-cm tumor from one part of the bladder billing 52235. At the same time the physician biopsies a suspicious-looking mucosal lesion in a different location billing 52204-59. The key to billing modifier -59 with bladder tumor removal is the separate location.
 
Many coders find the ""with or without biopsy"" verbiage in the descriptor for 52224 confusing. This code is for a lesion that is so small that the urologist might excise all of it ""incidental to'' the process of performing a biopsy. The urologist may fulgurate the entire lesion in which case there is no specimen for biopsy. For either case use 52224. Many urologists also treat minor lesions by removing them for a biopsy and then fulgurating around them. The procedure should be coded 52224.
 
Note: A common misconception is that ""tumor"" denotes malignancy. It doesn't; a tumor is simply a large lesion pathology unknown.

Correctly Coding Reoperations

On rare occasions a urologist removes a large bladder tumor transurethrally in two sessions. For example the patient has a 6-cm tumor and the urologist removes 3 centimeters. He or she removes only half because it's a large tumor and the resection takes over an hour after which time the risk of complications may increase.
 
Several days later the urologist completes the tumor removal another 3 centimeters. There are two ways to code this reoperation: with modifier -52 on the code for the larger tumor or with the code for the size representing the portion removed. Either is appropriate depending on your coding style.
 
Method 1: Bill 52240 with modifier -52 (reduced services) appended for the first operation Ferragamo says. For the reoperation bill 52240-52 again and this time append modifier -58 (staged or related procedure or service by the same physician during the postoperative period) to show that the procedure is staged he says. Even though modifier -58 is not needed for payment (52240 like all the bladder tumor removal codes has a 0-day global) it gives a more specific and clear idea of why the urologist is billing 52240 again.
 
Method 2: Some coders prefer to avoid modifier -52 in this case especially for Medicare. ""It's not appropriate since we have a code that describes exactly what was done each time 52235 "" Page says. ""Also the modifier -58 concept does not apply at least for Medicare since there are no follow-up days and therefore no staging."" If however the payer uses a non-Medicare RVP 15 follow-up days are assigned to the bladder tumor removal and modifier -58 would then be appropriate.
 
Page suggests 52235 for the second encounter when the last 3 centimeters of tumor are removed based on the size of the lesion removed at that time. ""A brief letter of explanation may need to accompany the claim explaining why the lesion wasn't removed in its entirety at the first encounter "" she says.

Don't Code for Wide Margins

Coders familiar with integumentary procedures may be confused by Medicare's rule against aggregating bladder tumor size. But coding for skin lesions and bladder tumors although similar does not really follow the same guidelines or rules. Laceration repair codes (12011-13160) under CPT and Medicare rules may be added up by size. Skin lesion removal (11400-11646) also in the integumentary section of CPT does not allow for aggregating by size; neither does bladder tumor removal.
 
On a related topic many coders are familiar with wide-margin coding rules which also come from the integumentary section of CPT. Under these rules code for the original size of the lesion not for the wide margins Page says. CPT says wide-margin removal of lesions should be based on the length of the diameter of the lesion not the wide margins.
 
""I believe the premise is the same whether coding for a skin lesion or an organ lesion "" Page says. But with bladder tumors this doesn't often happen because the urologist cauterizes the entire area around the tumor. Do not include that area of cautery in measuring the bladder tumor size.
 
Note: Code 52214 (cystourethroscopy with fulguration [including cryosurgery or laser surgery] of trigone bladder neck prostatic fossa urethra or periurethral glands) is in the bladder tumor section of CPT but is really a ""wastebasket"" code. It is used to describe fulgurating a bleeding vessel following a tumor removal or to treat an infection of the trigone or for a variety of other procedures that do not include bladder tumor removal itself.
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