Urology Coding Alert

Question: The patient had distal left prepuce 1.5 cm dilated penile thrombosed skin vein with painful erections and ejaculation. After verbal informed consent was obtained, the patient was placed supine, the distal shaft washed with Betadine, and my urologist used 3.0 mL of 2% lidocaine underneath the distal left foreskin. He next made a transverse 2 cm incision, carefully dissecting down identifying a prepuce vein, with middle dilated portion. 4-0 Vicryl sutures were placed on either side. The vein was carefully removed with underlying cauterization of the soft tissue. Small portion, elliptical in nature 1.5 cm slice was removed. My urologist used a two-layer closure given the patient’s blood thinner usage. He used a running 4-0 Vicryl on the undersurface of the soft tissue and a second on the actual skin. There was still excellent cosmetic reconstruction appearance and minimal discomfort. The patient was provided several days of antibiotics and a full description of how to keep the region dry after a shower and to apply antibiotic cream over the next week. How should I code the following? My urologist performed this procedure in his office.

AAPC Forum Member

Answer: You should report the following codes on your claim:

• 12041 (Repair, intermediate, wounds of neck, hands, feet and/ or external genitalia; 2.5 cm or less) for the layered closure
• 11422 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm) for the vein excision, 1.5 cm.