Surgical pathology coding for the urinary bladder is relatively straightforward, certain keywords in the documentation will ensure proper coding and subsequent reimbursement. Per the AMA’s Current Procedural Terminology (CPT), there are three options for coding urinary bladder specimens: 88305, 88307 and 88309. These codes should be applied as follows:
88305 – Urinary bladder biopsy. This code applies regardless of the surgical approach. Multiple biopsies can be submitted, and each is separately billable provided they are submitted in separate containers.
88307 – Urinary bladder TUR/TURB. 88307 is assigned when the specimen is a transurethral resection which should be indicated on the surgical requisition and/or specimen container, and also specified on the final pathology report. Multiple specimens are billable provided they are submitted in separate containers.
88309 – Urinary bladder partial/total resection. Regardless of diagnosis, this code applies to bladder resections other than transurethral.
"APS performed a comprehensive Coding Audit Review and subsequent financial impact assessment resulting in a significant increase in our revenue."