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Reader Question: Follow Payer Guidelines for Whether Adding Tumor Sizes Is Allowed

- Published on Thu, Dec 14, 2017

Question: One of our providers performed a biopsy on the bladder dome, trigone, and prostatic urethra. I can't decide whether to code it as 52214 or 52224-52240. What do you recommend?

West Virginia Subscriber

Answer: If your urologist did just multiple biopsied of the bladder and did not treat or remove the tumors, bill code 52204 (Cystourethroscopy and biopsy[s]) once. However, if he resected or fulgurated the multiple tumors and removed them completely along with biopsy, the correct coding will depend partly on whether you are filing to Medicare or a commercial insurer.

Since the removed tumors will provide tissue for biopsy, do not also code separately for the biopsy. If resected, commercial insurers allow you to combine the tumor sizes to reach the correct code, so you can potentially submit a higher-level code such as 52235 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] and/or resection of; MEDIUM bladder tumor[s] [2.0 to 5.0 cm]) or 52240 (... LARGE bladder tumor[s]).

Medicare, however, requires billing for only the largest tumor removed and does not allow you to combine tumor sizes to reach a higher level. Depending on the tumor in question, you might need to report the code forsmaller tumors, 52234 (... SMALL bladder tumor[s] [0.5 up to 2.0 cm]).

In either case, a code based on the tumor's size is more appropriate than 52214 (Cystourethroscopy, with fulguration [including cryosurgery or laser surgery] of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands).  

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