Urology Coding Alert

Question: The urologist performed a circumcision on an 80-year-old male. The diagnosis was phimosis. Notes state that the frenulum was taken down using a clamp, cautery, and cut technique. The urologist made circumferential skin incisions at the distal shaft. I’m debating between reporting 54150 and 54161. What’s your advice?

Kentucky Subscriber

Answer: Because the urologist did not use the Gomco bell shaped clamp (device) normally used for circumcisions in infants or small children, do not bill code 54150 (Circumcision, using clamp or other device with regional dorsal penile or ring block). Instead, report 54161 (Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age).

In the case you describe, the clamp placed on the frenulum is a hemostat to control bleeding after the frenulum is incised; it is not the bell-shaped Gomco device reported with 54150. In addition, the circumferential skin incisions indicate the open circumcision, which is code 54161.

Include diagnosis N47.1 (Phimosis), which can be used for either congenital phimosis or phimosis secondary to infection.

Refresher: Phimosis describes a condition in which the foreskin is too tight to be pulled back over the head or glans of the penis. In adults, there are a number of risk factors and causes of phimosis, though it only tends to be a problem if it causes symptoms.