Use Neoplasm Codes for Confirmed Pathology Results
Question: A patient presented to the urologist complaining of blood in their urine. After reviewing the patient’s history and performing a physical examination, the urologist ordered a cystoscopy for later that week to examine the patient’s urethra and bladder. During the cystoscopy, the urologist discovered a suspicious growth in the bladder, so they performed a biopsy. After reviewing the pathology results, the urologist diagnosed the patient with a malignant neoplasm of the anterior bladder wall. What codes should we report? New York Subscriber Answer: The urologist performed a diagnostic cystoscopy, which then proceeded to a cystoscopy with a biopsy. For this procedure, you’ll assign 52204 (Cystourethroscopy, with biopsy(s)), as this code includes both the biopsy and the examination. You’ll then turn to the ICD-10-CM code book to assign the diagnosis code. Since there is a documented confirmation of the neoplasm from the pathology results, you’ll use C67.3 (Malignant neoplasm of anterior wall of bladder) to report the malignant neoplasm of the anterior bladder wall diagnosis. Remember: If you did not have confirmation of the growth’s pathology at the time of coding, you’re better off assigning codes based on the patient’s symptoms, such as R31.9 (Hematuria, unspecified). Mike Shaughnessy, BA, CPC, Production Editor, AAPC
