Urology Coding Alert

Question: My urologist carried out a cystoscopy and transurethral resection of bladder tumors with fulguration on a patient with a history of bladder cancer and bladder tumors. According to the medical records, the patient was taken to the operating room (OR). Anesthesia was administered by the anesthesiologist. The patient was positioned in dorsal lithotomy position and the area was prepped and draped in the standard sterile manner. The urologist then accessed the bladder through the urethra using a 21-French cystoscope sheath. The bladder was examined with 30- and 70-degree lenses. The patient had a papillary tumor at the bladder neck, around the right ureteral orifice and in different areas around the bladder neck. The urologist removed the cystoscope sheath. A 25-French resectoscope with an obturator was used to enter in the bladder via the urethra using a standard electrode loop. The questionable areas in the right bladder neck, the right ureteral orifice, left bladder neck were resected, and any small tumors and mucosal abnormalities around the bladder neck were cauterized. An Ellik evacuator was then used to remove leftover tissue and once the patient had good hemostasis, the resectoscope was removed. The size of the largest tumor was 1.0 cm. A 22-French 3-way Foley catheter in the bladder via the urethra was inserted and the balloon was inflated with 15 mL of sterile water. The patient was taken out of dorsal lithotomy position, extubated, and taken to the recovery room in stable condition. Which codes should I report for this procedure?

North Dakota Subscriber

Answer: According to Stephanie Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime urology coding expert and consultant in Glen Burnie, Maryland, for this operative note, code 52234 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)) would be the correct choice for this scenario. Use the CPT^® code for the most extensive tumor resection, as most are bundled into the more extensive procedure. For multiple bladder tumors resected/treated at the same encounter, most carriers will require you to code for the largest tumor resected, which will also include the removal of any multiple, smaller tumors.

You should also report C67.5 (Malignant neoplasm of internal urethral orifice) for the ICD-10-CM code to justify medical necessity for the procedure.

Coding note: Here are some additional codes to report resecting bladder tumors depending on the size of the tumor(s) documented in the operative report:

• 52214 (Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands)
• 52224 (… or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy)
• 52235 (... and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm)
• 52240 (... and/or resection of; LARGE bladder tumor(s)).