# Looking for help with coding Hypospadias (cosmetic?) repair PRETTY PLEASE



## Kelly_Josephine (Dec 23, 2015)

I am relatively new and coding for ASC. I have been getting better with my Uro codes but this case today has me baffled. I am not sure of the dx or CPT coding. I am wondering about skin and uro codes... I am considering unlisted 55899 but this may not fly with the ASC. Here is the op note and I am hoping some kindly soul will set me straight on this:

PRE/POSTOPERATIVE DIAGNOSIS: Excessive skin and moderate skin thickening after major hypospadias repair. (Q55.23, N47.8, Q54.2? Doesn't seem like I would code hypospadias since this was previously treated?)

OPERATION PERFORMED: A major penile skin revision and scrotoplasty minor. (54161, 55175, and/or 55899? Doesn't seem like 54340-54352 fit as the actual complication was already treated. Maybe something with 14040 or 15740 but those don't really fit either? My best guess would be 13131-13133 with 55175 - but I have no measurements!) 

INDICATION: This boy had undergone a hypospadias repair for penoscrotal hypospadias. He then had a fistula, which had to be closed. After this, the family was somewhat unhappy with the overall appearance of the penis. I explained to them that with major hypospadias, the appearance with slightly thickened skin and slightly recessed penis is not all that unusual, but they were very interested in pursuing revision of the skin. Also explained to them that at times even with skin revision, the result will still perhaps not be satisfactory to their eyes. They, however, wanted to go ahead with things.

OPERATIVE PROCEDURE: Under adequate endotracheal induced anesthesia, the penis was draped and prepped 1n sterile fashion. A 4-0 Prolene was placed through the glans as a stay.

We inserted a 5 feeding tube with dilute Betadine attached to a syringe and injected into the urethra including urethra tethered skin towards the bottom aspect of the penis, which was pulling things down. It looked like an area where the old fistula had been.

We started by carefully marking an inverted V on the penis at the level of the frenulum to drop down these areas and then this tissue if it looked like it could be thinned down. This was opened carefully with microsurgical scissors. The skin was slightly thin here. Distal circumcising incision was then marked and inscribed and the shaft skin was dropped down. The tissues of course had a fair degree of scarring in the subcutaneous tissues to Buck's fascia. This made the dissection somewhat tedious, but ultimately we completely dissected the skin entirely off of the phallus. We also took a lot of scarred and thickened dartos fascia and some thickened Buck's fascia off of the penis circumferentially. No inadvertent injuries were made into the urethra. This was checked with retrograde injection of dilute Betadine.

After completely mobilizing the tissues, we started as I mentioned, I thinned out the penis.  This was done extensively.

We then started to work on the shaft skin itself to remove scarred tissue from under the surface, thinned it out, and try to get a cosmetically more pleasing result.

After adequately thinning out the tissue and removing some of the upper scrotal fat, we started by closing the dorsal circumcising incision after cutting away some tattered tissues. Before doing this, we excised skin under the mucosal collar to allow them to lay more flat.  Circumcising incision was started to be closed, working around from the dorsum towards   the ventrum. When we reached 3 and 9 o'clock positions, we elected to tack the skin at the shaft of the penis to the underlying tunica albuginea of the corpora cavernosa to assure fixity of the skin and maintain the length of the penis. This was done with interrupted sutures of 5-0 PDS. We then continued to bring the closure around laterally and towards the midline ventrally the mucosal collars had previously been closed with 6-0 plain.

In the depths of the wound, at the penoscrotal Junction we then sutured the dartos fascia to fascia overlying the corpus spongiosum to the dartos fascia and decided to further secure the penoscrotal Junction region. This was with interrupted sutures of 5-0 chromic.

We then further tailored the skin ventrally, closing it with 6-0 plain. Excised part of the upper scrotum and similarly closed that to flatten it nicely.


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## Kelly_Josephine (Dec 24, 2015)

Hoping someone will see this and offer some advice...


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## JEYCPC (Dec 30, 2015)

Look here:

http://www.hypospadie.info/images/script_hadidi.pdf

and here:

http://www.auanet.org/advocacy/pab/view.cfm?i=4718&a=12406


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