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Welcome to episode 301 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter, Dr. Ray Painter. And today we want to just revisit bladder tumor coding and documentation. Want to kind of go over it. We are adding this particular category to our hub, our PRS Coding and Reimbursement Hub. So if you go to PRSnetwork.com forward slash urology hub, you'll be able to see this in the this should be added in the next week or two. So the last week of August in 2026. So keep an eye out for that. All right. Mark, let's go over bladder tumors. You want to take us through kind of the pitfalls and what we need to avoid in the documentation and what we need to include in the documentation and what we need to be aware of for billing bladder tumors. Bladder tumor resections.

Alright. So we are going to focus today on cysto or cystoscopic approach for bladder tumors and that coding that's there, that's the most common. Obviously, we do have some open procedures, and then of course, the other side, we're going to focus on non-muscle invasive, which oftentimes involves a little bit more open coating and a few different codes. So we'll stick in this primarily in the category of bladder tumors removed through the use of a scope. And we've talked about some of this before, but a few of the big things that we absolutely want to see within the documentation for coding of bladder tumor resection or fulgaration are the size of the tumor. That's one of those things that you want to estimate or measure and document in your chart. We've got two different issues that we run up against quite frequently. One is a focus on the size of the lesion created with the removal rather than the size of the tumor. So the focus here, based on the CPT verbiage, is the tumor and the tumor size. We also have with T URBTs in all of this section, the 522, 14, 2, 4, 3, 4, 3, 5, and 40, we have the parenthetical S sitting there. So that's one of those things that you gotta keep an eye on as you're going through all of this coding, is that unfortunately we cannot bill for more than one T URBT code, and because they're all mutually exclusive, and with the exception of the 52214, um, we've got that parenthetical note that talks about lesion lesions. So we're not really allowed to bill for multiple units of each of these codes. And the 52214 does have an MUE of one, and that's a data service edit, so it's not appealable. So even though it doesn't say multiple areas, we do have that secondary issue of the interpretation from the payer that we only get a bill one for each one that we do. Now there's a couple of other things that you want to pay attention to other than size of tumor, because this is where size matters. It really does matter with the 5224, 34, 35, and 40. We have ranges of what bladder size is there. We've had discussions in the past where people thought about adding up all the size of the tumors. Unfortunately, the opinions we've gotten from the AMA and AUA is that it is about the largest tumor that was removed. So everything would roll up into that if you removed one of those larger tumors. So if you're drilling a 52240, you're kind of stuck with the 52240, even if you removed a bunch of smaller tumors that would have counted in other codes. So you've got that one issue that's up there. So that, and that is a very common issue with records review. Now, typically the payer does not see the size of the bladder tumor when you're submitting the bill because they're not looking at the documentation in processing a lot of your claims. However, we have seen a number of chart reviews or medical records requests from the payers each time they see these codes coming in the door. So that's one of the first things that you want to do is make sure that when you get into the bladder, you document the size. Second thing related is where is it located? Is it on the dome? Is it in the trigone? Is it on the lateral wall or the posterior wall? Where is that tumor located? Then you want to make sure that you're using the right diagnosis code because that and that brings us to yet another common denial, which is the diagnosis code for the bladder tumor or bladder malignancy is does have different locations. That's the C67, and all the way up through 0.8, so 0.67.1, 67.2, 0.3, 0.4, 0.5, 0.6, all are specified play locations within the bladder, and you want to do that. Now the 8 is overlapping, which means that you've identified a tumor that's on more than one wall or in more than one location for that bladder tumor because it's grown that way. So that's the other one. And then the point nine, unfortunately, is the prop. The 67.9 is bladder cancer site unspecified, which we're seeing more and more of the payers reject as a non-specific code, even though it has the full number of digits, because their belief is if you're treating a bladder cancer, you should have known where you removed it from. And that you have a hard time disagreeing with. Now, the administravia of not paying for the C67.9, that is just good clinical hygiene being coding hygiene being forced on you by the payers. So you want to make sure you're documenting the location and the size as you get in and start looking around. You do want to code because these are all pretty much any method coding resolutions. Select among the codes, make sure that you're selecting the right diagnosis. And I'll talk to that a little bit more because we don't have to use bladder cancer to do to do a TRBT if we don't know or are not sure that in fact this was a bladder cancer. All of these are also zero-day globals. So you're gonna have to use a modifier 25 in order to get paid for an ENM on the same day. And of course, that means all the rules for modifier 25 have been met, that the documentation includes a separate and significant and identifiable service in addition to the bladder tumor codes that are being built. Ray, comments, questions?

Mark, you get a lot of questions of why not just use the pathology report on size of tumor.

Yeah, so we got a cut we get a couple of questions that come in from that, and so that's a great question. One is the as Ray just asked, what about the size? Well, we know that sizes tend to be different when they get removed from the body and then placed into sample vials. So that's one thing that you want to estimate or get a measurement before you do the surgery, so you know what size you're removing, and then go ahead and submit it to pathology. And even if their size is different, your size would be the overruling size and would actually make it appropriate for what you're trying to bill. And then the second thing is what do you know? Now we talked just briefly ran over the C67 codes, but those aren't the only options to use for TUR bladder tumor. We get a lot of questions from folks about D41.4, which is essentially bladder uncertain neoplasm of the bladder, which is very different from what we see in most cases. The definition of uncertain really is focused on a result back from pathology, and the results of that being inconclusive as to whether or not it's a malignancy. So that's the D41.4. The more commonly used version of this code is D49.4, unspecified behavior of the pathology for a bladder cancer. And D49.4 is really descriptive of those bladder cancers that you haven't yet biopsied. Maybe they looked a little bit different than a full-blown cancer. So you're you don't know what it is, and you won't know until you get that result back from the pathologist. So you want to make sure that you know ultimately you're clear on what you know and what you don't know, but don't be afraid to use the D49.4 for those cases that you just haven't had a biopsy done and you don't know for sure based on their appearance.

So with the D49.4, you're that's not site specific, so you don't have to include a site on that because there's no other ICD 10 code to describe that. Is that correct?

That is correct. No. No? No. Because even though you've got a tumor that you've removed that you just don't know whether it's a cancer or not, you still removed it from a certain site. So shouldn't you still include the site?

Well, you can include the site in the documentation, and that'll be helpful down the road for certain, but it's not gonna affect the code itself. So I guess I was answering a different question that if it's based on just the coding, the the D forty nine point four does not have a location other than bladder. So you're not gonna change that diagnosis based on location, like you are with the malignant neoplasm codes, which require a different digit for that location. So you do it is from uh from the easy standpoint. If you're pushing the easy button, it's easy to leave it out and you probably won't hurt that particular claim. However, as often is the case, those come back as positive. And if you don't have the location documented in the note, then it makes it tougher for your billing team to support you in selection of that appropriate C67 code when you're doing the next treatment, whether that's drugs or surveillance, whatever that you're doing, now that you have that positive diagnosis of cancer, you want to make sure that you are using that more specific location code with the malignancy. So Yeah, that was my go ahead.

I was just gonna say you you also have made the point indirectly that you code about what you see at the time you see it, you don't wait for the pathology report to turn in your bill.

You said it way better than I did. I only implied it, but you did you you are correct. Like code for what you know at the time you do the procedure, or what you know at the end of the procedure. If you got a frozen section back by the end of the procedure and you know it's cancer, you could do that. And then the second thing I'll add in is that you don't necessarily have to have pathology to code the malignancy. If you know clinically it's bladder cancer, you can choose that according to ICD 10 guidelines. But you do want to be careful that does have a significant ramification for the patient. So either know it by sight or know it because they had it before and you know this is a recurrence, or code it as unspecified and wait for the pathology to actually diagnose the patient with cancer.

That's a good point. And we also ought to mention you get paid for the unspecified just the same way you would if it was labeled as cancer. So don't use the cancer unless you know what you're talking about. Even though this is the one time that they allow you to, and I'm not sure you're it the the coding says it anywhere else, that you can make the clinical diagnosis. Most of it, they want you to have a pathology report.

Actually, that is a statement in the ICD 10 guidelines that the clinician codes to what they know. So then that so that little interpretation of no is very different, right? I mean, essentially it's not about that you've confirmation through pathology. It's really is about what the physician knows at the end of the encounter. So it really applies to everything. It just comes up more frequently with bladder cancer because of recurrence of bladder cancer and the appearance of bladder cancer is oftentimes visual and a little bit easier for the experienced urologist to make that call than some of the other diagnoses and treatments that we deal with in urology. This podcast episode is supported by Eurogen, manufacturer of Zesturi. Zesturi, mitamycin for intervesical solution, is indicated for the treatment of adult patients with recurrent low-grade intermediate risk non-muscle invasive bladder cancer. Please visit zesturi.com for more information.

Thanks for clarifying that. We've often heard in urology that was the one you could do.

Yeah. All right. Yeah, I think it's easy to extrapolate, that's for sure. And but it's also, you know, it's part of the way it works.

All right, I got and you may have been poised to cover this next, Mark, but I got a question on installations. So if you have a drug installation that you routinely do when you do a T R B T, can you get paid for that in if you're doing it the same day?

It depends on how you're doing it and when you're doing it and all of those things. Because now this is where there's a little bit of a difference between the codes. So from the NCCI, which is our bundling document with our bundled codes and code pairs and all that other stuff, the 522 343540 all state that the 51720, which is your installation code, is considered bundled into the bladder tumor removal. But the 52214 and the 5224 do not include the 51720 in the bundling that's set out within the NCCI. So you've you don't need modifiers. Oh, I said that wrong. The 517 or the 5224 does include the 51720. But the 1.4 and then the biopsy, the 04, as you would expect, do allow without modifiers for the 51720. Now, when we look at bundling and what's going on with the bundling matrix, the NCCI, we've got to think about more than just whether or not we can add a modifier. And that's the other piece that we run into, as we've seen interpretations with the payers going a little bit deeper. The 51720, which is the installation code, really requires a catheterization and the installation of the drug. And that process of the installation during the surgery, many of the payers have come back stating that you know the catheter is really put in as part of the procedure. The installation really is not a separate installation, not that the drug cannot be billed, but the actual physical installation is not separately billable. What we have seen, however, though, is if the installation is done in a separate encounter. So you could support the XE modifier or just the separate encounter that a 59 allows. We've had success billing for that circumstance because in fact it was a totally separate effort. It was a totally separate encounter.

So you mentioned that you can bill for the drug if you don't if you even though you can't bill for the the installation, is that how does that work?

Well, so the we had a discussion several years ago where a number of the payers were requiring an installation or an injection code with drugs. But there are procedures like these 522 codes that do allow for a drug to be billed without a separate installation code. So because the drug is different, that is something that you can report the J code straight up in addition. to the procedure the five two two two four three four three five or four zero. All right. Of course you want to make sure that you've prior authorized that. As we've had in some of our other discussions.

Yes. All right. Anything more you want to add, Mark, to this discussion.

Let's see. The other thing that I would add from the diagnostic side of the equation is that many of your bladder cancer patients start their journey because of hematuria. And I did want to clarify with everyone that hematuria, even though it's present, if you know the cause is really related to the bladder cancer. We don't use or continue to use or not supposed to continue to use the hematuria codes as it becomes part of the disease state diagnosis. So you want to make sure you practice good diagnostic hygiene and remove the hematuria code when you've moved to the bladder cancer codes or the unspecified codes that you use for those bladder cancers. Then the other one that we didn't address with any detail was the the D41.4 other than to mention that it's pathology that determines it's uncertain. But it could also it also is one of those that you would be able to remove or should remove the hematuria code if you believe that is the source of the bleeding.

All right.

Ray, anything to add no other than just the old saying the devil's in the detail so be sure you document what you should all right well let's wrap this episode up here.

If you're in the market for an EHR or practice management system you can go to modmed.com forward slash PRS network for specials for our listening audience. We want to thank modmed for supporting this episode. We also want to thank Eurogen for supporting this episode. You can go to Zusduri.com for more information on Zusduri or gelmito.com for more information on gel mito. We thank our sponsors for making these podcasts possible. All right let's get some final thoughts.

Mark final thoughts yeah so you know I think that a lot of us take some of these commonly used codes a little bit for granted and don't always put in the detail that we know needs to be there and that's what we see in documentation that's out there. So don't get lazy on your documentation. Remember that if you're billing an EM code on the same day it's got to have that 25 modifier. Make sure that your support is separate and I think most of you know but I'll just add in there that with these bladder cancer codes we do not see as many EMs on the same day because that patient journey relative to their cancer is related and really is hard to totally separate out because you've potentially already diagnosed what's going on. So you want to be careful in using modifier 25. You want to make sure that documentation's there make sure your diagnosis coding is correct and as we talk about with everything make sure you do your prior offs and all that stuff that's required.

The administrative of healthcare these days is the biggest hurdle we've seen in all of these issues and it all goes back to appropriate documentation appropriate orders and good support across the board from your team Ray final thoughts as you've heard us say many times before this this whole system is not complicated but it is detailed starting with your documentation all right well let's end this episode here I do want to remind you that your the Urology Advanced Coding and reimbursement seminar registration is open and please be on the lookout for a Labor Day special for Labor Day 2026. So we'll be sending that out via email and you can also check it out on the site if you go to PRSnetwork.com and click on the seminar registration that'll give you more information as well. Also I mentioned earlier that the PRS coding and reimbursement hub this bladder tumor page will be updated and up and available on the hub. So you can go to PRSnetwork.com forward slash urology hub and click on the category of bladder tumors through a scope and you'll see the information in writing of what we talked about today. So we want to make sure that you have that and it's available at your fingertips when if you need to refresh or whenever you need a review. Alright that's all we have for today thank you all for listening take us out right and happy coding and billing thank you for listening to the Urology Coding and Reimbursement Podcast where we help urologist understand maximize income and efficiency so there's time and energy for patient care and a happy life special thanks to our pointer for the music today you can find this music on Spotify under its record label YouTube.