Urology Coding Alert

Never append modifier 63 to 54160.

When your urologist performs a circumcision, you must check the documentation for numerous details, including the surgical approach your physician used and the age of the patient. For example, you will report a different code for a circumcision via a clamp or other device versus a circumcision via a surgical excision.

Read on to always submit clean circumcision claims in your practice.

Tip 1: Determine Age of Patient to Choose Correct Code

When it comes to circumcision, you have three procedure codes to choose from.

Code 54150: Report 54150 (Circumcision, using clamp or other device with regional dorsal penile or ring block) for a surgical “clamp” circumcision. Urologists usually performs a 54150 service for a newborn, using a Plastibell device.

Caution: Never append modifier 63 (Procedure performed on infants less than 4 kg) to 54150, per CPT^®. If your urologist performs a 54150 service without a dorsal penile or ring block, you should append modifier 52 (Reduced services).

Code 54160: Report 54160 (Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate [28 days of age or less]) for a surgical circumcision in a patient who is 28 days of age or younger. Note: Never report modifier 63 in conjunction with 54160, per CPT^®.

Code 54161: Report 54161 (Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age) for the surgical circumcision of males older than 28 days of age and for adults. This code includes the lysis of adhesions and takedown of the frenulum.

Don’t miss: To choose the appropriate and correct code from the above choices, you must know both the age of the patient and the surgical method your urologist used.

Coding circumcisions can be difficult if the approach is not clearly defined, explains John Piaskowski, CPC-I, CPMA, CUC, CRC, CGSC, CGIC, CCC, CIRCC, CCVTC, COSC, specialty medicine auditor at Capital Health in Trenton, New Jersey and surgical coding consultant at Memorial Care Health System in Huntington Beach, California. Most circumcisions involve the use of a bell-shaped clamp in order to swiftly remove the foreskin from the glans, with minimal bleeding. The other open approach involves a direct surgical incision and foreskin excision.

Report code 54150 when your urologist performs a circumcision using a clamp or other device. On the other hand, report codes 54160 and 54161 when your urologist performs a circumcision via a surgical excision other than a clamp, device, or dorsal slit.

Age is also a factor when the surgical excision approach is taken. Code selection is determined by whether the patient is within the neonatal age (28 days or younger) or outside of the neonatal age range, Piaskowski says.

Tip 2: Don’t Forget Appropriate ICD-10-CM Code

Most circumcisions are routine or for social or religious custom and would be coded as Z41.2 (Encounter for routine and ritual male circumcision), Piaskowski says. However, there are certain conditions where circumcision is clinically necessary such as penile cancer, phimosis, penile gangrene/ infection, or other penile complications. It is imperative that the indication for the service be documented, as most payers have set reimbursement policies for routine circumcision.

Some common diagnoses that payers may determine as medically necessary for a circumcision include N47.1 (Phimosis), N47.2 (Paraphimosis), N47.5 (Adhesions of prepuce and glans penis), N47.6 (Balanoposthitis), N48.1 (Balantitis), C60.0 (Malignant neoplasm of prepuce), and A63.0 (Anogenital [venereal] warts). However, payers will have their own policies on acceptable diagnoses, so always check your payer’s policy.

Phimosis defined: Phimosis describes a condition in which the foreskin is too tight to be pulled back over the head or glans of the penis. In adults, there are a number of risks factors and causes of phimosis, though it only tends to be a problem if it causes symptoms.

Balanitis defined: Balanitis occurs when the head of the penis is swollen and sore.

Balanoposthitis defined: Balanoposthitis is inflammation of the foreskin and glans in uncircumcised males.

Tip 3: Always Mind NCCI Edits

Circumcisions follow the global surgery rules and are subject to National Correcting Coding Initiative (NCCI) edits, so if multiple surgeries are done at the same time (if it is not a routine circumcision), be mindful of bundling of codes, Piaskowski cautions.

Closure, simultaneous reduction of penile shaft torsion, nerve blocks, and nerve repair are generally bundled into circumcisions and not separately billable, adds Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook.