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

• Pathology & Stage/Grade: e.g., Ta, low-grade (no CIS). Include variant histology, lymphovascular invasion (if present), and whether detrusor muscle is present in specimen.
• Tumor Burden: size (cm) of largest tumor, number (solitary vs. multifocal), and location(s).
• Recurrence History: date of prior TURBT(s), time since last recurrence, and response/tolerance to prior intravesical therapy (BCG/chemotherapy) with start/stop dates.
• Resection Quality: “Complete resection” vs. “residual disease suspected,” hemostasis achieved.
• Immediate Post-op Instillation (if given): agent, dose, route (intravesical), and dwell/retention time.
• Planned Course: induction/maintenance intravesical schedule or re-TURBT plan; surveillance interval.
• Medical Necessity Rationale: symptoms (e.g., gross hematuria), imaging/cystoscopy findings, guideline risk category (intermediate-risk, recurrent LG Ta), and why intervention is required now.

Pro tip: Always document largest lesion size and number—these drive code selection for TURBT/fulguration and reduce denials.

1. Diagnosis/Surveillance: cystoscopy ± cytology/biopsy.
2. Treatment: office fulguration of very small recurrent lesions or TURBT for larger/multifocal disease; consider single immediate intravesical chemo post-TURBT when appropriate.
3. Adjuvant Therapy: intravesical induction (chemotherapy or BCG) with risk-adapted maintenance.
4. Follow-up: cystoscopic surveillance on an intermediate-risk schedule.

Select one tumor-removal code per side/session based on largest lesion size treated.

• 52000 – Cystourethroscopy (diagnostic)

• 52204 – Cystourethroscopy with biopsy
• 52214 - Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands
• 52224 – Cystourethroscopy with fulguration/treatment of minor lesion(s) <0.5 cm, with or without biopsy

• 52234 – Small tumor(s) 0.5–2.0 cm; fulguration and/or resection
• 52235 – Medium tumor(s) 2.0–5.0 cm; fulguration and/or resection
• 52240 – Large tumor(s) >5.0 cm; fulguration and/or resection

Intravesical Therapy Administration (same session or on treatment visits)

See Example Below

• Most transurethral bladder procedures are 0-day global (endoscopic/minor). Verify with your MAC fee schedule for each code.

Bill drug supply separately from administration (51720). Units depend on dose.

• Mitomycin for Intravesical Solution (ZUSDURI™) – J9999 (bill drug under a miscellaneous antineoplastic code unless your payer has issued a specific HCPCS or requires an alternative unlisted code); check current MAC/plan guidance. FDA-approved June 12, 2025 for adult recurrent low-grade, intermediate-risk NMIBC.
  Dose: 75 mg (56 mL) once weekly x 6 via intravesical instillation; supplied as a kit (two 40-mg vials + 60-mL hydrogel).

Box 19:
Use Box 19 to document the NDC number, drug name, route of administration, and dosage given. If billing with a miscellaneous code, record any drug wastage here.

Example: A patient receives 75 mg from an 80-mg vial. The remaining 5 mg should be documented as wastage. So the Box 19 entry could be written like: 72493010603 ZUSDURI Instillation ME75 ME5JW
Do not substitute J9280.

• Mitomycin – J9280 (Injection, mitomycin, 5 mg) — for traditional IV/instillation mitomycin vials.
• Gemcitabine – J9201 (Injection, gemcitabine HCl, 200 mg)
• BCG – Verify current MAC policy; historically billed with J9030 (per mg) or J9031 (per instillation). Follow your payer’s active code and units.

Pair C67.x site-specific malignant neoplasm codes with treatment/encounter Z-codes as appropriate.

• C67.0 – Malignant neoplasm of trigone of bladder
• C67.1 – Malignant neoplasm of dome of bladder
• C67.2 – Malignant neoplasm of lateral wall of bladder
• C67.3 – Malignant neoplasm of anterior wall of bladder
• C67.4 – Malignant neoplasm of posterior wall of bladder
• C67.5 – Malignant neoplasm of bladder neck
• C67.6 – Malignant neoplasm of ureteric orifice
• C67.7 – Malignant neoplasm of urachus
• C67.8 – Malignant neoplasm of overlapping sites of bladder
• C67.9 – Malignant neoplasm of bladder, unspecified

• Z51.11 – Encounter for antineoplastic chemotherapy (e.g., mitomycin, gemcitabine)
  (List as principal diagnosis)
• Z51.12 – Encounter for antineoplastic immunotherapy (e.g., BCG)
  (List as principal diagnosis)
• Z85.51 – Personal history of malignant neoplasm of bladder (use for surveillance when no active disease)

Note: ICD-10-CM does not capture grade/stage—keep these in the documentation.

• Biopsy bundling: 52204 is bundled into certain lesion-treatment codes (e.g., 52224). Biopsy may be separately reportable with size-based TURBT codes (52234–52240) only when performed on a distinct lesion or normal mucosa mapping in a separate location; check NCCI edits and payer policy.
• Single code for multiple tumors: When removing multiple tumors, choose the code based on the largest lesion treated in that session. Document total tumor burden.
• Modifier –22 (unusual procedural services): Consider when operative time/complexity is well beyond typical (e.g., diffuse multifocal disease requiring extensive resection/fulguration). Justify with clear detail.
• Laterality modifiers (LT/RT): Not applicable to bladder (single organ).

Example A – Office/ASC Minor Recurrence

Surveillance cystoscopy identifies a 0.4 cm papillary LG Ta lesion on posterior wall; lesion fulgurated.

Code(s): 52224.
Dx: C67.x site-specific.
Tip: If a separate biopsy of normal mucosa mapping is performed in a different location, 52204 may be added per NCCI rules.

Example B – TURBT + Immediate Mitomycin

Two recurrent LG Ta tumors, 1.5 cm and 0.8 cm, completely resected; immediate intravesical mitomycin instilled with 40 mg dwell.

Code(s): 52234 (largest lesion 1.5 cm), 51720 for instillation; J9280 x 8 units for 40 mg mitomycin (payer-specific).
Dx: C67.x site-specific; Z51.11 for chemo encounter.

Example C – Induction BCG Visit

Weekly intravesical BCG induction without cystoscopy.

Code(s): 51720; HCPCS: payer-specific active BCG J-code and units; Dx: Z51.12 (immunotherapy encounter) ± C67.x when treating active disease.

Example D – ZUSDURI™ (Mitomycin for Intravesical Solution)

Office visit instillation 75 mg (56 mL) for recurrent LG-IR NMIBC.

Code(s): 51720 (administration).
HCPCS (drug): J9999 (miscellaneous antineoplastic), include NDC 72493-0106-03 (kit) and actual dose/units per payer; do not use J9280.
Dx: Z51.11 (encounter for antineoplastic chemotherapy) ± C67.x when treating active disease.

Box 19:
Use Box 19 to document the NDC number, drug name, route of administration, and dosage given. If billing with a miscellaneous code, record any drug wastage here.

Example: A patient receives 75 mg from an 80-mg vial. The remaining 5 mg should be documented as wastage. So the Box 19 entry could be written like: 72493010603 ZUSDURI Instillation ME75 ME5JW

Checklist – – What to Include in the Op/Procedure Note

• Largest tumor size and number; location(s)
• Complete vs. incomplete resection; presence of detrusor muscle in specimen
• Hemostasis achieved; complications (if any)
• Agent/dose/units/retention for any intravesical therapy
• Guideline risk category documented (e.g., Intermediate-risk, recurrent LG Ta) and planned surveillance interval

Practice Tips

• Put a standard phrase in your templates for size/number/location and agent/dose/retention time—this alone reduces denials.
• When disease is multifocal but all small, document aggregate burden and largest size; choose code off the largest.
• Align your drug units (HCPCS) with actual dose administered; keep the vial/NDC on file per payer.