Urology Coding Alert

Question: The urologist performed a surgical removal of the skin bridges located at the frenulum and dorsal side on an adult patient who had previously undergone circumcision as a child. Should I report 54162 or 54163 for this procedure?

Tennessee Subscriber

Answer: You should report 54162 (Lysis or excision of penile post-circumcision adhesions) as this code is used for the surgical correction of penile adhesions, which can include skin bridges.

Don’t miss: Before you report 54162, check whether the lysis involved instrumentation and general anesthesia. If your urologist could easily, manually break down the post-circumcision adhesions without using an instrument to cut the adhesions, you should not report 54162, but you would choose an appropriate evaluation and management (E/M) code instead.

Do not choose 54163 (Repair incomplete circumcision), as this is specifically used for the revision of a circumcised penis, which includes the “surgical correction of the penile skin and mucosal sleeve.” This typically refers to procedures that correct issues directly related to the circumcision itself, such as excess or insufficient removal of foreskin. In the scenario you provided, the urologist is performing a surgical removal of skin bridges. Skin bridges are not a direct result of circumcision, but rather a complication that can occur when the circumcision wound heals.

Therefore, the procedure is not a revision of the circumcision, but a separate procedure to address a specific issue.