Wiki multiple bladder tumor resection - MA

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connollyjenn

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Hi, looking for some assistance, I have always understood that when coding for bladder tumor resection ( 52224, 52234, 52235, 52240) we only code for the largest tumor. Codify has a coding alert for 02.2025 suggesting that private payors may allow you to add multiple tumor sizes that matches the code. I have yet come across a payor policy allowing this? I know Medicare is an absolutely no. But now I have one of our physicians asking me about adding the sizes of a bladder tumor? I do not see any cpt guidelines in the 2025 book for these codes?! also see this link. https://search.app/cgVbC7QwGXf5pwoo7, I am grateful for any direction.
 

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I didn't find anything from CPT guidelines clear cut policy on bladder tumor resection. The guidelines are basic: the selection of CPT code based on the size not by number. Tumor size is based on a visual estimate of tumor at cystoscopy. And payor policies do vary. For Medicare, bill the single tumor code with the largest single tumor size removed. For private and commercial payors, add the tumor size . I also consider the society's recommendation American Urology Association for coding and reimbursement. I am attaching a link to a podcast, this is a great discussion between Dr. John Lin and the coding gurus from the society Mark, Scott and Dr. Ray Painter. The Painters are well known in the urology coding, reimbursement and practice management.
 
In working with all the information out there, especially Medicare. I provide this for my providers.
I request for them to put that key word OVER, to know for sure.

Cystourethroscopy With Fulguration &/or Resection of Tumors

Size guideline for resection of bladder tumors:

  • 52224-lesion size less the 0.5 cm., minor
  • 52234 lesion size 0.5 cm to 2 cm., small
  • 52235 lesion size over 2 cm. to 5 cm., medium
  • 52240 lesion size over 5 cm., large


Note: To help capture 52240, document over 5cm, and to help capture 52235, document over 2 cm.



Medicare instructions

Cystourethroscopy With Fulgration and/or Resection of Tumors (Codes 52234, 52235, and 52240).

The descriptors for codes 52234 through 52240 include the language "tumor(s)”.

This means that regardless of the number of tumors removed, only one unit of a single code can be billed on a given date of service. It is inconsistent to allow payment for removal of a small (code 52234) and a large (code 52240) tumor using two codes when only one code is allowed for the removal of more than one large tumor. For these three codes only one unit may be billed for any of these codes, only one of the codes may be billed, and the billed code reflects the size of the largest tumor removed.

Additional Codes



52204 " Cystourethroscopy, with biopsy(s)

Note: When a biopsy and fulguration of a bleeder within the biopsy site without treatment of a lesion, you should only report 52204, as this code also includes the fulguration. "If fulguration is used only to stop bleeding from the biopsy site, it's included in the biopsy and you would bill 52204,"


When you're "treating" a small lesion less than 0.5 cm in size with biopsy and complete fulguration, code 52224. In other words, if the physician biopsied a minor lesion and then fulgurated its base or any remaining part of the lesion, use 52224.

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52214 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands)



Note: Use 52214 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands) for fulguration of a bleeding vessel(s) in the bladder, such as in a case of radiation cystitis (no biopsy) or the treatment/fulguration of a Hunner's ulcer associated with interstitial cystitis.





Opportunity for additional code capture.

If your urologist treats a bladder tumor that is larger than 0.5 cm and you report 52234, 52235, or 52240, you may also be able to separately report a bladder biopsy under certain circumstances. If the urologist biopsies normal mucosa (mapping), a bladder red patch, or only biopsies another bladder tumor, and all lesions are in distinct areas that are separate and different from the initial tumor site, report the biopsy separately. Use 52204 and append modifier 59 (Distinct procedural service) to indicate that the biopsy was a separate procedure at a separate site. CCI version 15.0 bundles 52204 into the resection codes 52234, 52235, and 52240, but you can bypass these bundles with modifier 59 (Distinct procedural service) since they have a modifier indicator of "1."



Example: 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 coding 52204-59. The key to coding modifier -59 with bladder tumor remo
 
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