Urology Coding Alert

Scour the documentation to find the ‘proof’ to support your claim.

Most urologists are not called in to perform routine pediatric circumcisions, and many payers won’t reimburse you for cosmetic procedures, so proving the medical necessity for an adult circumcision is essential for your coding success. 

Let our experts guide you through the proper procedure and diagnostic codes to report to reflect the clinical circumstances that warrant payment for your urologist. 

1. Decide on Procedure Code

The first step in coding a circumcision case is to decide on the appropriate procedure code to report. Depending on the surgical method your urologist uses, you will have three CPT® codes to choose from as follows: 

• For a surgical “clamp” circumcision, report 54150 (Circumcision, using clamp or other device with regional dorsal penile or ring block)
• For a formal surgical circumcision in a patient who is 28 days of age or younger, you should assign 54160 (Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate [28 days of age or less]).
• Report surgical circumcision of males older than 28 days of age (including adults) with 54161 (Circumcision, surgical excision other than clamp, device or dorsal slit; older than 28 days of age).

Hint: If your urologist doesn’t perform pediatric procedures, you’ll only need to look to 54161. “54150, for clamp platsi-bell, is usually performed at the request of a parent of a newborn,” explains Christy Shanley, CPC, CUC, billing manager for the department of urology at the University of California, Irvine.

Don’t miss: Typically, your urologist will use a local anesthetic during the circumcision procedure. However, that doesn’t mean you can separately report the nerve block using 64450 (Injection, anesthetic agent; other peripheral nerve or branch). The surgical code is considered inclusive of the injection procedure, Shanley warns. Note, if your urologist does not perform a block, you should attach modifier 52 (Reduced services) to 54150 as stated in the 2015 CPT® manual. 

2. Home in on the Diagnosis

Since most payers won’t pay for circumcisions performed for cosmetic or religious reasons, you must prove medical necessity via your diagnostic coding. 

When the circumcision is medically necessary, you must use the appropriate diagnosis code to ensure reimbursement. Two typical diagnoses that payers reimburse as medically necessary are phimosis (605, Redundant prepuce and phimosis) and balanitis (607.1, Disorders of penis: Balanoposthitis, balanitis), Shanley says.

Payers have their own policies on acceptable diagnoses, so if your urologist performs a circumcision for a diagnosis not represented by one of the above codes, don’t assume the surgery isn’t covered. Plus, keep in mind that your payer may require preauthorization even for medically necessary circumcisions. Check your payer’s policy.

Alternative: If the patient wants a circumcision, and you know your payer will not cover the procedure, ask the patient to sign a waiver or an advance beneficiary notice to inform him that he may be responsible for payment. For adult or pediatric circumcision performed for cosmetic or religious reasons, link diagnosis code V50.2 (Routine or ritual circumcision) to the circumcision code.

3. Don’t Overlook Counseling Payment

Typically, before your urologist performs a circumcision he may provide an E/M service or counseling concerning the procedure. You can often report this counseling work, Shanley says. 

Circumcision counseling sometimes can take a long time, especially if the patient has questions and is trying to make up his mind about having the procedure. If your urologist spends more than 50 percent of the encounter on counseling, you may be able to select the E/M level based on time.