Stephanie Ellis, RN, CPC (president of Ellis Medical Consulting): As a general rule, that is correct — especially with coding breast biopsies, suspicious lesion removals, hysterectomy codes based on the weight, etc. It is not necessary to wait on the pathology if the physician is doing a colonoscopy and states he or she removed a colon polyp. In that case, it is okay to bill the 211.3 diagnosis and send the claim. However, if the physician states it was a “suspicious colon polyp,”I would wait on the pathology report before coding. Also, if a lipoma is removed and the physician states definitively in the operative report that it is a lipoma, it is okay to bill the 214.X lipoma diagnosis and send the claim.
Q: My specific issue is with the urologists performing cystoscopy related to bladder tumors — CPT codes 52234, 52235, 52240. I have always waited to obtain the pathology report for size verification of the specimen as many urologists have their offices code for the “large” specimen when the pathology report reveals a much “smaller” size. I have attempted to explain this “waiting for the pathology report” but the urologist emphatically states “it’s large.” I need supportive documentation to show to the urologist that the pathology report is a clear method of determining what applicable CPT code to bill to the insurance carrier.
SE: I feel your pain with this particular issue. Unfortunately, the pathology report will only help you so much with bladder tumors. Because these codes are used whether the physician fulgurates or excises the tumor, the pathology will help with sizing if he excises the tumor; however, if he fulgurates it, the pathology will not help you with sizing and it is only useful for the diagnosis of cancer or not. When they fulgurate the tumor, it is destroyed and they will just send off pieces and parts of it to pathology for histology to see if it is cancer, rather than the entire specimen(s), as in an excision procedure. Below is an excerpt from my coding seminar about how to code these procedures, but again, the documentation must be detailed about sizing if the fulguration method is used.
52235—Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm)
Bladder Tumors
The physician’s documentation must be extremely detailed to correctly code these procedures. These codes have special coding guidelines. Bill one code for each size/area of lesion removed (bill applicable code once for single or multiple tumors in the same size section). For example, if the surgeon fulgurates/resects two small lesions, one medium tumor and three large tumors, bill code 52234 x 1, code 52235 x 1 and code 52240 x 1. Do not add tumor sizes together to code; each tumor should be measured individually to determine the appropriate category from which to code.
Note: CPT codes are copyrighted by the AMA.
Ms. Ellis (sellis@ellismedical.com) is president of Ellis Medical Consulting, a healthcare consulting firm providing chart audits for coding and documentation issues, business office operational assessments, research of coverage issues, fee and coding revisions, litigation support, reimbursement research, coding/billing training, and the development and implementation of billing compliance programs for healthcare providers.
