Urology Coding Alert
Scrap 54440 Without Repair
Question: I need to know the code for penile exploration. The urologist wrote “Incision was made. Soft tissue damage only, no fracture. All swelling was in subcutaneous tissue, corpora was inspected and all appeared to be intact; very little trauma at the corporal level. Bleeding controlled and incision was closed.” Is 54440 correct even though there was no repair?
New Jersey Subscriber
Answer: There is no specific CPT® code for penile exploration. Your instinct is correct that 54440 (Plastic operation of penis for injury) is not correct.
You should instead report 54115 (Removal foreign body from deep penile tissue [eg, plastic implant]). Attach modifier 52 (Reduced services) indicating that your urologist performed only a penile exploration. Modifier 52 indicates this lesser procedure and the absence of a foreign body in the penile tissues.
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