Urology Coding Alert

Location is everything when performing a hypospadias repair.

The process of reporting hypospadias repairs can be complex due to the multitude of diagnosis code options available in ICD-10 and the variety of related CPT® codes. So, it’s crucial to understand the specifics of the case, such as the abnormal location of the hypospadias urethral meatus and whether the urologist conducted an initial single-stage or multi-stage repair, to accurately select the appropriate code.

We asked John Piaskowski, CPC-I, CPMA, CUC, CRC, CGSC, CGIC, CCC, CIRCC, CCVTC, COSC, specialty medicine auditor at Capital Health in Trenton, New Jersey, and AAPC consultant and committee chair, to help clear up some of the confusion related to coding hypospadias repairs, and here’s what he had to say.

What Is Hypospadias?

Hypospadias is a congenital condition where the urethra’s opening isn’t at the penis tip but rather on its underside, ranging from the penis’s distal part to the perineal area.

Which Code Will You Choose for Hypospadias?

Your hypospadias code selection is based upon the location of the meatus. The list below consists of the ICD-10 diagnosis codes you’ll report, along with some typical wording from practitioner’s notes related to newborn (NB) variants of hypospadias that will help you pinpoint the related code, according to Piaskowski:

• If the NB male has urethral meatus in malposition at the ventral glans of penis, you’ll report Q54.0 (Hypospadias, balanic).

Note: Code Q54.0 also includes coronal and glandular hypospadias.

• If the NB male has urethral meatus in malposition on the shaft of penis, you’ll report Q54.1 (Hypospadias, penile).
• If the NB male has urethral meatus in malposition at the junction of the penis and scrotum, you’ll report Q54.2 (Hypospadias, penoscrotal).
• If the NB male has urethral meatus in malposition in the perineum near the anus, you’ll report Q54.3 (Hypospadias, perineal).
• If upon routine neonatal examination, the NB in current intersex state has associated uniquely positioned urethra meatus, you’ll report Q54.8 (Other hypospadias).

Note: Code Q54.8 includes hypospadias with intersex state.

• If the NB male has a malpositioned urethral meatus, you would report Q54.9 (Hypospadias, unspecified). “This is typically used by pediatric specialists that are treating syndromes typical to hypospadias without exam confirmation of specific type of hypospadias. It’s not unusual to document solely the presence of hypospadias without the exact details of the urethral meatus position, as this is not usually necessary to examine for conditions outside of the urinary system,” says Piaskowski.

Coding tip: For accurate ICD-10 diagnosis code selection, it’s essential that the urologist clearly specifies the location of the hypospadias defect in the medical record.

Choose From These Options for Initial Single-Stage Repair

If the urologist performs an initial single-stage repair for hypospadias, you will choose one of the following:

• 54322 (1-stage distal hypospadias repair (with or without chordee or circumcision); with simple meatal advancement (eg, Magpi, V-flap)). Physicians usually use a meatal advancement or V flap to treat glanular hypospadias where the meatus is mobile. You will often see “Magpi” or “V-flap” in the medical documentation to refer to this procedure.
• 54324 (... with urethroplasty by local skin flaps (eg, flip-flap, prepucial flap). You’ll use this code for flap and tissue if the medical documentation supports this fact. You may see your urologist refer to this procedure as a “Mathieu” repair.
• 54326 (... and mobilization of urethra). You’ll use this code when your physician performs the hypospadias repair by using local skin flaps and the mobilization of the urethra. You may see your urologist refer to this procedure as a “Snodgrass/ Thiersh” repair.
• 54328 (... with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/or island flap). You’ll use this code when your physician corrects the hypospadias along with extensive dissection to correct chordee and urethroplasty by using local skin flaps, skin graft patches, or island flaps.
• 54332 (1-stage proximal penile or penoscrotal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap). You’ll use this code when your urologist corrects the hypospadias along with extensive dissection to correct chordee and urethroplasty by using grafted materials around the urethra and/or by island flap.
• 54336 (1-stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap). You may see your urologist refer to this procedure as a “Duckett” repair.

Coding tip: Initial, single-stage repair codes vary based on the surgical procedure and anatomical repair site. Use codes 54322-54328 for distal repairs, 54332 for proximal penile or penoscrotal repairs, and 54336 for perineal repairs.

Learn to Report Multi-stage, Initial Repair

If the hypospadias opening is far from the perineum and the penile tissues are poor, the urologist may choose a multi-stage repair for better healing and to avoid complications. In this case, the urologist would perform one of the following stages in the repair:

Stage 1: For the first stage of a multi-stage procedure, you can report one of the following codes:

• 54300 (Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra)
• 54304 (… correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce and/or skin flaps)

Stage 2: For the second stage of a multistage repair, you will choose from the following codes:

• 54308 (Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm) or 54312 (... greater than 3 cm)
• 54316 (…with free skin graft obtained from site other than genitalia)

Remember: Codes 54308, 54312, and 54316 include urinary diversion.

Stage 3: The third stage of a multi-stage repair, if necessary, should be reported using code 54318 (Urethroplasty for third stage hypospadias repair to release penis from scrotum (eg, third stage Cecil repair)).