Urology Coding Alert

Question: I can't seem to find sufficient procedure and diagnosis codes for the repair of a fractured penis. What code combination do you recommend I use to best describe this procedure? South Carolina Subscriber Answer: You may be having difficulty coding this procedure because it is a very uncommon disorder that is usually caused by abrupt bleeding from rupture of the corpora cavernosa (penile erectile tissue) due to blunt trauma to the erect penis. Because this condition is so rarely reported, it is one of those procedures that doesn't have a unique, easily identifiable diagnosis or procedure code. The exact codes required for the specific case you are coding will depend heavily on the content of the operative note, but here are two diagnosis/procedure code combinations that urology coders have used in the past to code repair of a fractured penis:

Diagnosis code 959.1 for injury to the external genital organs with procedure code 54440 (Plastic operation of penis for injury)
Diagnosis codes 959.1 and 867.0 (Injury to pelvic organs; bladder and urethra, without mention of open wound into cavity) combined with CPT code 54440 and CPT code 53505-51 (Urethrorrhaphy, suture of urethral wound or injury; penile; multiple procedures) for a patient with a penile fracture and an injury to the urethra. Be sure to read the operative note carefully, because some physicians may verbally describe the procedure as a repair of a fractured penis when the written report actually describes something as simple as incision and drainage of a hematoma, 54015. Answers to You Be the Coder and Reader Questions contributed by Morgan Hause, CCS, CCS-P, and coding specialist for Urology of Indiana in Indianapolis; Connie Copeland, with Urology Professional Association in Tupelo, Miss.; and Linda Whited, LPN, CPC, of Cooper Clinic, a physician-owned multi-specialty clinic in Pennsylvania; and answered and reviewed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook.