Urology Coding Alert

Question: My urologist is asking me if he can get compensated in addition to the office visit for the service that he performs when a patient comes to the office complaining of phimosis (605). The doctor reduces the adherent foreskin of the penis, but we cannot find a CPT code for that service. What should we report?

California Subscriber

Answer: In addition to the appropriate office visit code, you should report code 54450 (Foreskin manipulation including lysis of preputial adhesions and stretching), for the reduction of the adherent foreskin.

Since the latter is a surgical procedure, add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the provided E/M service to indicate that your urologist performed a separately identifiable E/M service.