bladder tumor size

[turnerdc@gmail.com]

If the op note does not list the size of a bladder tumor that was removed but only states as large can we code for large (52240) or must we charge for small (52224) since there are not sizes listed.

 

[ehanna]

If the op note does not list the size of a bladder tumor that was removed but only states as large can we code for large (52240) or must we charge for small (52224) since there are not sizes listed.

It's my understanding that documented size does matter

I would ask the doc to do an addendum and add the size if possible but without definitive measurement I don't think you can support the code. This might be a good educational opportunity moving forward with this provider if he can't document size in this particular case.

I hope this helps and am interested to see what others say about this.

Adding to this. I looked up the code and the small, medium, and large codes and all list size ranges. Without proper size documentation you would go with small if an addendum cannot be done.

 

[ckkohler]

Bladder Tumor Size

Hello!
If the physician does NOT document the actual size of the tumor or by stating "small", "medium" or "large" - you CAN defer to the pathology report and base your code off the measurements in the pathology report. If you physician performed a cystoscopy in the recent past - where the tumor was discovered, sometimes they'll indicate the measurement of what they found. That information can also be used to determine the code for the TURBT.