Urology Coding Alert

Question: When a urologist performs a frenuloplasty for a torn frenulum, which CPT Code should I use? In addition, if the physician is performing a frenuloplasty at the time of a circumcision, would the frenuloplasty be considered inclusive to the circumcision?

Georgia Subscriber

Answer: A repair of trauma or laceration of the frenulum (most often a linear tear), requires a suture repair or frenuloplasty, as you mentioned. The most common coding for this would include the use of one of the CPT codes in the 12001-12007 range (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet] ...), based on the length of the repair site.
 
Diagnosis solution: The appropriate diagnosis code for this procedure would be 959.14 (Injury, other and unspecified; trunk; other injury of external genitals).
 
Watch out: A frenulotomy (54164, Frenulotomy of penis), rather than a frenuloplasty, would certainly be included in a formal circumcision, which you would report using 54161 (Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn). In fact, the National Correct Coding Initiative bundles 54164 into 54161, so you should not report both codes at the same time.