Bladder Cancer (NMIBC): Recurrent, Low-Grade — Intermediate Risk

Coding & Documentation Overview

Recurrent, low-grade non‑muscle‑invasive bladder cancer (NMIBC) sits in the intermediate‑risk category. These cases have high recurrence risk but low progression risk, and management is typically risk‑adapted TURBT and/or intravesical therapy with structured surveillance. This page distills what urology teams need for clean documentation, correct coding, and predictable reimbursement.

Key Documentation Elements

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.

Typical Care Pathway (At‑a‑Glance)

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.

 Product Specific Coding and Reimbursement Information

ZUSDURI

Physician Coding – Common CPT® Codes

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

Diagnostic/Surveillance

• 52000 – Cystourethroscopy (diagnostic)

Biopsy & Minor Lesions

• 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

TURBT / Fulguration by Size

• 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

Global Period (typical)

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

Drug (HCPCS) Examples for Intravesical Therapy

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

• Mitomycin – J9280 (Injection, mitomycin, 5 mg) — for traditional IV/instillation mitomycin vials. Do not use J9280 for Zusduri (mitomycin for intravesical solution).

• Mitomycin for Intravesical Solution (ZUSDURI™) – bill drug under a miscellaneous antineoplastic code (e.g., J9999) unless your payer has issued a specific HCPCS; 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).
  Report Zusduri used and wasted separately (-JW for waste); document NDC, Lot #, Expiration Date, Total Used [xx mL (xx mg), Wasted: xx mL (xx mg); include both mL and mg
  Do not substitute J9280.

• 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.

Common ICD‑10‑CM Codes

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.

Other Coding Considerations & Edits

• 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).

Quick Examples

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) Visit
Office instillation 75 mg (56 mL) once weekly (week 3 of 6 in a series) 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.

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.