Urology Coding Alert

Question: My urologist performed the procedure below. What codes can I report?

Diagnosis: Phimosis with granular adhesions

Operative Notes: The patient was administered general anesthesia. Area was adequately prepped and draped. All the adhesions between foreskin and glans were carefully lysed. The frenular band was incised in a transverse manner and all the adhesions were lysed. The ventral aspect of the frenulum was then closed with 4-0 chromic catgut in an interrupted manner, in a longitudinal manner with straightening the ventral aspect of the penis. Foreskin was then held at 11 o’clock and 1 o’clock positions and an incision was made at 12 o’clock up to about 3 mm from the coronal junction. A similar incision was made at 6 o’clock and redundant foreskin on either side was excised. Hemostasis was obtained. Stay sutures using 3-0 chromic catgut were placed at 12 o’clock, 6 o’clock, 3 o’clock and 9 o’clock positions. Intervening skin to mucosa were closed with interrupted 4-0 chromic catgut sutures. A Xeroform dressing was applied and stay sutures were tied over the dressing to keep it in place. A penile block using 7 mL of 0.25% Marcaine was used at penile base. There were no intraoperative complications. Blood loss was less than 10 mL. The patient was stable throughout the procedure and was transferred to recovery room in stable condition.

Connecticut Subscriber

Answer: You should report 54161 (Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age) for this procedure.

Don’t be tempted to also report 54164 (Frenulotomy of penis). The frenuloplasty work is included in the circumcision code and therefore, 54164 is not separately reportable.

Official guidance: The CPT^® manual reinforces this with the statement “Do not report 54164 with circumcision codes 54150-54161, 54162, 54163” following code 54164.