Urology Coding Alert

Watch for the type of injury — and don’t confuse it with exploration.

Coding for penile repair due to a traumatic injury became easier a few years ago when CPT^® 2016 introduced two new codes for the service. They were welcome additions to your coding arsenal since the best option at the time, 54440 (Plastic operation of penis for injury), was nonspecific and used for a wide range of situations.

Read on for your refresher on how to report these cases, including encounters that involve only exploration rather than repair.

Pay Attention to Type of Injury for Traumatic Repair

The two codes you may choose for reporting penile repair of a traumatic injury are:

• 54437 (Repair of traumatic, corporal tear(s))
• 54438 (Replantation, penis, complete amputation including urethral repair)

These codes were a welcome addition to CPT^® because they reflect additional specificity, says Jonathan Rubenstein, MD, director of coding and physician compliance for Chesapeake Urology Associates in Baltimore.

“For example, a repair of a complete penile amputation, with 38.64 RVUs, shows the increased work compared to the less specific code 54440,” he says. “In general, the more accurate the code for a procedure, the more likely the provider will be reimbursed for the work that they do, without questioning whether the work they did is greater than the listed procedure or less than the listed procedure.”

Know the values: Code 54437 carries a total RVU value of 19.47 and reimburses $702.66 based on the 2020 national conversion factor of 36.0896. The work associated with 54438 is much more extensive and is reflected in its value: 38.64 total RVUs and payment of nearly $1,400 based on the 2020 national conversion factor.

Assign the diagnosis: When you report 54437, connect diagnosis S39.840A (Fracture of corpus cavernosum penis, initial encounter). Note that coding guidelines instruct you to also code an associated open wound from the S31 (Open wound of abdomen, lower back, pelvis and external genitals) range.

Procedure 54438 ties to diagnosis S38.221A (Complete traumatic amputation of penis, initial encounter).

Turn to the Best-Fitting Code for Exploration

Sometimes the urologist will perform penile exploration to determine what damage has occurred and to what extent.

The current CPT^® manual does not include a code for penile exploration, so you’ll need to assign one that most closely matches the physician’s service based on the individual situation.

Scenario: Consider this example of provider notes from a Urology Coding Alert subscriber: “Incision was made. Soft tissue damage only, no fracture. All swelling was in subcutaneous tissue, corpora was inspected and all appeared to be intact; very little trauma at the corporal level. Bleeding controlled and incision was closed.”

In this scenario, the correct option is 54437 (Repair of traumatic corporeal tear(s)). Attach modifier 52 (Reduced services) to indicate that the urologist performed only a penile exploration rather than the full service represented by 54437. Modifier 52 explains that in this case, the surgeon performed this lesser procedure (only the wound exploration) and the absence of any repair of penile tissues.

Caveat: Be sure to read the operative note carefully for every case, because some physicians may verbally describe the procedure as a repair of a fractured penis (or other traumatic injury) when the written report actually describes something as simple as incision and drainage of a hematoma: 54015 (Incision and drainage of penis, deep). Always use the written documentation as your best guide to code selection.