Pediatric Coding Alert

Question: Our pediatrician released a penile adhesion from a patient that had a circumcision, which was performed by a different doctor. Can I report 54162 (Lysis or excision of penile post-circumcision adhesions)? I have read about this code, and some literature states that the patient needs to have been under general anesthesia. The CPT^® book does not state it has to be. Can you let me know if this is a requirement?

Codify Subscriber

Answer: Unfortunately, there is no black and white answer to this question—the answer depends on how the lysis is being performed. If they are just pulling the foreskin down to release the adhesions, then there is no code for that. This particular service is typically done without an instrument and you would report an E/M code for it. This shouldn’t be an issue considering that your doctor is not the same physician who performed the actual circumcision, so global rules will not apply. 

If the physician instead uses instrumentation to remove the adhesions and you use topical or regional anesthesia beforehand, then you can report 54162 (Lysis or excision of penile post-circumcision adhesions), assuming the documentation is sufficient for this code.