Cystoscopy with TURBT (Transurethral Resection of Bladder Tumor)

CPT 52235
Approach Endoscopic
Add-on / Variant CPTs
  • 52234 — Cystourethroscopy with fulguration/resection of small tumor(s), <0.5 cm
  • 52240 — Cystourethroscopy with fulguration/resection of large tumor(s) >2 cm
  • 52000 — Cystourethroscopy, diagnostic only (no biopsy or resection)
  • 52204 — Cystourethroscopy with biopsy (no resection)
  • 52250 — Cystourethroscopy with insertion of radioactive substance
Preoperative Diagnosis:

Bladder tumor — [papillary / sessile / solid] — [X] cm at [lateral / posterior / trigone / dome] wall, noted on [CT urogram / office cystoscopy]

Postoperative Diagnosis:

Same

Procedure Performed:

Cystoscopy with transurethral resection of bladder tumor (TURBT) [and fulguration]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Nurse/tech name]

Anesthesia:

General endotracheal [/ spinal / MAC]

Indications:

The patient is a [age]-year-old [male/female] with a [X]-cm bladder tumor identified on [hematuria workup / surveillance cystoscopy]. CT urogram confirmed the lesion without upper tract abnormality. TURBT was planned for diagnostic and therapeutic resection. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

Cystoscopic examination demonstrated a [X]-cm [papillary / broad-based / solid] tumor at the [lateral / posterior / dome / left / right] wall [X o'clock position] [near the ureteral orifice]. The remainder of the bladder was [normal / with [X] additional small papillary lesions]. The ureteral orifices were [bilateral normal position / uninvolved]. No carcinoma in situ (CIS) was apparent [/ suspicious areas were biopsied].

Description of Procedure:

The patient was positioned in the dorsal lithotomy position. The genitalia were prepped and draped. A [26-Fr] rigid cystoscope was introduced transurethrally. A complete cystoscopic survey of the bladder was performed — all walls, trigone, dome, ureteral orifices, and bladder neck examined.

The tumor was identified at [location]. A [26-Fr] resectoscope with [cutting loop] was introduced. The tumor was resected systematically from the top (exophytic portion) to the base, including [3–5]-mm margins of normal mucosa. [Muscular] tissue was included in the base resection to assess for muscle invasion.

Specimens were sent separately: [exophytic portion separately from the base with muscle]. Hemostasis was achieved with the [coagulating loop / fulguration]. [Additional cold cup biopsies were taken from [random sites / CIS-suspicious areas] for mapping.]

A [20 Fr] 3-way urethral catheter was placed for continuous bladder irrigation. The bladder was irrigated with [sterile water / glycine] until clear.

Complications:

None

Specimens:

Bladder tumor — exophytic portion: pathology
Bladder tumor base with muscle: pathology (sent SEPARATELY — critical for staging)
[Random biopsies / CIS sites: pathology]

Estimated Blood Loss:

Minimal

Drains:

[20 Fr 3-way catheter for continuous irrigation] / [18 Fr Foley]

Disposition:

The patient was taken to the PACU in stable condition. Continuous bladder irrigation was maintained until the effluent cleared. [Intravesical mitomycin C [40 mg in 40 mL] was instilled within [6 hours] post-operatively for single-dose prophylaxis in low-risk NMIBC.] Pathology results to guide adjuvant intravesical therapy planning.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Bladder tumor — *** cm at ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Cystoscopy with TURBT
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General/spinal

INDICATIONS: .PTAGE-year-old .PTSEX with *** cm bladder tumor on ***. TURBT planned for diagnosis/treatment. Consent obtained.

FINDINGS: *** cm *** tumor at *** wall/o'clock position. Remainder of bladder ***. Ureteral orifices ***.

PROCEDURE:
Dorsal lithotomy. Genitalia prepped. 26 Fr cystoscope. Complete survey: findings above. Resectoscope introduced. Tumor resected top to base, *** mm margins, muscle included in base. Specimens sent SEPARATELY: exophytic and base with muscle. Hemostasis: coagulating loop/fulguration. [Random biopsies: ***.] [Post-resection MMC *** mg instilled.] 3-way catheter *** Fr for CBI. Irrigated until clear.

EBL: Minimal
SPECIMENS: Exophytic tumor and base with muscle — SEPARATELY to pathology
COMPLICATIONS: None
DISPOSITION: PACU, CBI until clear. [MMC instilled.] Pathology to guide further treatment.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Photodynamic Diagnosis (Cysview / Blue-Light Cystoscopy)

Cysview (hexaminolevulinate hydrochloride) [50 mg] was instilled intravesically [1 hour] prior to the procedure. Cystoscopy was performed with [white light followed by blue light fluorescence imaging]. Under blue light, [X] additional lesions were identified that were not visible under white light — [flat CIS lesions / satellite lesions]. These were resected and biopsied. Blue-light cystoscopy improves detection of CIS and flat lesions compared to white light alone and is recommended for initial staging TURBT and high-risk surveillance.

Charting Tips
  • Send the tumor base specimen SEPARATELY from the exophytic specimen, as staging depends on the presence of muscularis propria (detrusor muscle) in the specimen. A single combined specimen may result in the pathologist not being able to determine invasion depth. Document 'base with muscle' as a separate specimen in the operative note.
  • Document the location of the tumor by clock face and distance from the ureteral orifice. Bladder tumors near the ureteral orifice require special consideration (may need DJ stent, possible ureteral involvement). Document 'tumor located [X] cm from the right ureteral orifice.'
  • Document perioperative intravesical mitomycin C (MMC) for low-risk NMIBC. A single-dose post-operative intravesical MMC within 6 hours of TURBT reduces recurrence by 40% in low-risk disease. Document that it was given, the dose, and the time since TURBT. This is an AUA guideline recommendation.
Billing Tips
  • TURBT code selection by tumor size: 52234 (small, <2 cm, 4.50 wRVU), 52235 (medium, 2–5 cm, 5.30 wRVU), 52240 (large, >5 cm, 7.31 wRVU). Document the largest tumor dimension in the operative note.
  • 52204 (cystoscopy with biopsy only, 2.53 wRVU) is for biopsy without resection. Use when obtaining mucosal biopsies for carcinoma in situ (CIS) mapping or random biopsies.
  • Global period is 0 days (endoscopic). There is no post-procedure global, so follow-up cystoscopies are separately billable.
  • If multiple tumors are resected, bill the code corresponding to the largest individual tumor; multiple smaller tumors do not stack up to a higher code tier.
  • Blue light cystoscopy (Cysview): add-on code 52204 is used for diagnostic cystoscopy with photodynamic guidance. Some payers cover separately; verify prior authorization.
  • Fulguration of residual tumor or base after TURBT is bundled into the resection code. Do not bill 52214 (fulguration) separately for the same tumor bed.
  • Bladder biopsies taken in addition to TURBT: 52204 may be billed with modifier -59 if biopsies are from separate, distinct sites not contiguous with the resected tumor.