Urology Coding Alert

Question: A patient with dementia placed numerous key rings around his penis. They did not penetrate through the skin but were placed around the outside of the penis. Would code 54115 be appropriate with a 52 modifier because the foreign object was not in deep penile tissue as the description of that code reads?

Pennsylvania Subscriber

Answer: If the provider removed numerous penile rings that were not inside the body of the penis, you should not use 54115 (Removal foreign body from deep penile tissue [e.g., plastic implant]), as this code represents deep foreign body removal. Appending modifier 52 (Reduced services) does not change the descriptor of the procedure code. Instead, you’ll need to report the unlisted code 55899 (Unlisted procedure, male genital system) because CPT^® does not have a code for this situation. To indicate the location of the penile foreign body on the outside of the penile shaft, append ICD-10 diagnostic code S30.852A (Superficial foreign body of penis; initial encounter).