Learn if TURBT Includes a Biopsy Procedure
Question: I have an op note for a transurethral resection of a bladder tumor (TURBT). The urologist described the procedure as a “cold-cup clamshell biopsy of the bladder” as well as resecting a tumor measuring 3 to 5 cm. What procedure codes should I report for the TURBT? Revenue Cycle Insider Subscriber Answer: The TURBT procedure you described included two components — biopsy and tumor resection — but you will report only one procedure code. Assign 52235 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm)) to report the tumor resection based on the size documented in the op note. This is a more extensive procedure and inherently includes the cold-cup clamshell biopsy of the bladder. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
