Ensure these are explicit in the note/op/report:

• Pathology & Stage/Grade: e.g., Ta, low-grade (no CIS)…
• Tumor Burden: size (cm), number, location(s).
• Recurrence History: date of prior TURBT(s)…
• Resection Quality: “Complete resection”…
• Immediate Post-op Instillation: agent, dose, route, dwell time.
• Planned Course: induction/maintenance schedule…
• Medical Necessity: symptoms, findings, risk category…

1. Diagnosis/Surveillance: cystoscopy ± cytology/biopsy.
2. Treatment: office fulguration or TURBT…
3. Adjuvant Therapy: intravesical induction…
4. Follow-up: surveillance schedule…

Select one tumor-removal code based on largest lesion size treated.

• 52000 – Cystourethroscopy

• 52204 – Biopsy
• 52214 – Fulguration…
• 52224 – Minor lesion(s) <0.5 cm…

• 52234 – 0.5–2.0 cm
• 52235 – 2.0–5.0 cm
• 52240 – >5.0 cm

Bill drug supply separately from administration (51720).

• ZUSDURI™ – J9999 (misc. antineoplastic; payer-specific)
• Mitomycin – J9280 (traditional)
• Gemcitabine – J9201

• C67.0 – Trigone of bladder
• C67.9 – Bladder, unspecified
• Z51.11 – Encounter for antineoplastic chemotherapy
• Z51.12 – Encounter for antineoplastic immunotherapy

• Biopsy bundling: 52204 may be bundled…
• Multiple tumors: code off the largest lesion.
• Modifier –22: use only with strong documentation.

Example A: 52224 …

Example B: 52234 + 51720 …

• Document size/number/location
• Document agent/dose/dwell time
• Use templates to reduce denials