Urology Coding Alert

Reader Questions:

Remember to Report Z-Code in This Case

Question: The patient was brought into the operating room and placed on operating table. After administration of appropriate prep and drape of the lower abdomen penis perineum and anterior thighs, my urologist made a degloving incision beginning approximately 1 cm proximal to the corona of the glans penis. Appropriate plane was entered, and my urologist was able to deglove the penis back to the deviation of the corpora cavernosa. There was no evidence of defect within the corpora and the urethra appeared intact. Since the patient did not have blood at the meatus and was able to void immediately post-incident, my urologist did not perform a cystoscopy. At this point, my urologist carefully looked for active bleeding and did not identify any. The proximal shaft skin was reapproximated to the mucosal skirt using interrupted 3 O chromic sutures circumferentially. Finally, my urologist applied a light dressing with bacitracin ointment to the incision line, and the patient was taken to the recovery room in stable condition. What codes should I report on my claim?

AAPC Forum Subscriber

Answer: You should report the following coding for your clinical scenario:

  • 54437 (Repair of traumatic corporeal tear(s))-52 for a reduced procedure to repair a corporal tear. Note: Your urologist did not find a corporal tear, so you should append modifier 52 (Reduced services).
  • The procedure was performed for a suspected diagnosis of S39.848A (Other specified injuries of external genitals, initial encounter), but a rupture of the corpus cavernosum was not found. Therefore, add to your diagnosis of S39.848A code Z71.1 (Person with feared health complaint in whom no diagnosis is made).