Urology Coding Alert

If you're using diagnosis codes for cosmetic or religiously motivated circumcisions in adult and pediatric patients, you won't get reimbursed no matter how hard you pray.

Not all payers will reimburse for adult and pediatric circumcisions without diagnosis codes that reflect medical necessity, and pinpointing covered diagnosis codes won't be easy because of varying policies among carriers, says Trenda Lee, CPC, reimbursement specialist for the University of Missouri department of surgery in Columbia.

Typically, the circumcisions urologists perform are not for newborns, but for males over the age of 6 months, and the procedure code is 54161 (Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn), says Angelique Hope, CPC, coding specialist for Cincinnati Children's Hospital.

Make Adult Decision to Use 5 Surefire Diagnoses

You can count on one hand the primary diagnosis codes commonly reported for adult and pediatric circumcision, for procedure code 54161: paraphimosis and phimosis, history of urinary tract infections, balanitis, venereal warts, and cancer of the foreskin.

One of the most common indications for adult and pediatric circumcision is phimosis, Hope says. Phimosis is a condition of the penis in which the prepuce can't be drawn back to uncover the glans penis, and paraphimosis is the condition in which, once being drawn back to reveal the glans penis, the prepuce can't be put back in place. Both phimosis and paraphimosis are represented by diagnosis code 605 (Redundant prepuce and phimosis). When a urologist chooses to treat phimosis or paraphimosis with circumcision, report CPT 54161 and link it to ICD-9 Codes 605.

A second medically necessary diagnosis for 54161 is inflamed foreskin resulting from frequent, recurrent urinary tract infections (UTI) a coding scenario that has more demanding ICD-9 coding requirements. To be reimbursed for 54161 for inflamed foreskin from a UTI, it is imperative that you report two diagnosis codes, one for the inflamed foreskin and another for the UTI. Report inflamed foreskin diagnosis code 607.1 (Balanoposthitis) as the primary diagnosis code, and the appropriate UTI code as the secondary diagnosis code. Reversing the order of the diagnosis codes will surely result in a denial.

The third covered indication for adult circumcision is alanitis "" more commonly described as an infection of the foreskin. When a patient presents with a diagnosis of balanitis you won't necessarily be coding a circumcision though. Balanitis can occur in diabetics where glycosuria and retained urinary droplets within the foreskin after voiding can induce infection. Balanitis can also be second to a sexually transmitted disease. But if the balanitis also known as balanoposthitis is a result of hygiene neglect in uncircumcised males irritation of a baby's foreskin from a wet diaper or tight foreskin (phimosis) often the urologist will perform a circumcision 54161.

Two additional reliable indications for procedure code 54161 are venereal warts or condyloma (078.11) and cancer of the foreskin (187.1). Aurologist might turn to circumcision for condyloma acuminatum present on the foreskin when the condyloma has increased in size or has been unresponsive to topical treatment. Likewise when a male has penile cancer confined to the foreskin a circumcision procedure can be the curing treatment.

Lee points out that covered diagnosis codes can vary from carrier to carrier so if your urologist performs a circumcision for a diagnosis not represented by one of the above codes don't assume it isn't covered.

And as always you should provide the most specific diagnosis codes possible when linking them to CPT Codes 54161 and feel confident when submitting your claim that when a patient presents with a complication motivating the circumcision your chances are pretty good for getting paid Hope says.

'To Do's'Before Noncovered Circumcisions

On rare occasions coders are asked to code circumcisions provided for religious or cosmetic reasons. And you have to append the proper diagnosis codes for these circum- cisions as you do for medically necessary ones regardless of whether you are getting paid.

For adult or pediatric circumcision performed for cosmetic or religious reasons link diagnosis code V50.2 (Routine or ritual circumcision) to the circumcision code.

Preoperatively it is a good idea to inform the responsible party ahead of time that they may be responsible for the bill for the circumcision Hope says it will help to avoid payment complications or delays after the procedure has already been performed. This should be done in writing using a waiver or an advance beneficiary notice.