Urology Coding Alert

Hint: Report Q54.0 for balanic hypospadias.

You may find reporting hypospadias repair challenging because ICD-10-CM offers numerous diagnosis code options, and CPT^® offers many procedure codes. For example, you will need to know both the abnormal location of the hypospadias urethral meatus and whether your urologist performed an initial single stage or multi-stage repair in order to choose the correct code.

Read on to learn more.

Tip 1: First, Understand What Hypospadias is

Hypospadias is a congenital condition in pediatric patients where the opening of the urethra, the tube that carries urine from the bladder to the outside of the body, is not located at the tip of the penis. Instead, the opening of the urethra is on the underside of the penis, anywhere from the distal portion of the penis to the perineal area. Hypospadias can be proximal (behind the scrotum), middle, shaft, or distal (near the head of the penis). There are different degrees of hypospadias. Some can be minor and some more severe.

Symptoms of hypospadias include the following:

• Chordee, which is when the penis curves downward
• Undescended testicle, which occurs when one of the testicles doesn’t fully descend into the scrotum
• Undeveloped foreskin, which occurs when the skin that covers the head of the penis isn’t complete
• Abnormal urination, which occurs when the urine doesn’t pass in a straight stream

Tip 2: Rely on These ICD-10-CM Codes for Hypospadias

Your hypospadias code selection is based upon the location of the meatus. Your ICD-10-CM code choices for hypospadias include the following:

• For balanic hypospadias, which is malposition of the urethral meatus on the ventral glans penis, you should report Q54.0 (Hypospadias, balanic). Note: Code Q54.0 also includes coronal and glandular hypospadias.
• For penile hypospadias, which is malposition of the urethral meatus on the shaft of the penis, you should report code Q54.1 (Hypospadias, penile).
• For penoscrotal hypospadias, which is malposition of the urethral meatus at the junction of the penis and scrotum, you should report code Q54.2 (Hypospadias, penoscrotal).
• For perineal hypospadias, which is malposition of the urethral meatus in the perineum near the anus, you should report code Q54.3 (Hypospadias, perineal).
• Q54.8 (Other hypospadias). Note: Code Q54.8 also includes hypospadias with intersex state.
• Q54.9 (Hypospadias, unspecified). Note: This code is rarely reported with the availability of the above ICD-10-CM codes, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook.

Coding tip: Your urologist must identify the hypospadias abnormality, citing the location of the defective meatus in the medical documentation for you to choose the appropriate ICD-10-CM code.

Tip 3: Choose From These Options for Initial Single-Stage Repair

If your urologist performs an initial single-stage repair for hypospadias, you will choose one of the following codes:

• 54322 (1-stage distal hypospadias repair (with or without chordee or circumcision); with simple meatal advancement (eg, Magpi, V-flap)). Note: Physicians usually use a meatal advancement or V flap to treat glanular hypospadias where the meatus is mobile. You will often see “Magpi” or “V-flap” in the medical documentation to refer to this procedure.
• 54324 (... with urethroplasty by local skin flaps (eg, flip-flap, prepucial flap), (use for a Mathieu repair)). Note: Flap and tissue transfer codes may be reportable along with 54324 if the medical documentation supports this fact. You may see your urologist refer to this procedure as a “Mathieu” repair.
• 54326 (... with urethroplasty by local skin flaps and mobilization of urethra, (use for Snodgrass/Thiersh repairs)). Note: When your physician performs a 54326 service, they will perform the hypospadias repair by using local skin flaps and the mobilization of the urethra. You may see your urologist refer to this procedure as a “Snodgrass/Thiersh” repair.
• 54328 (... with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/ or island flap). Note: When your physician performs a 54328 service, they will correct the hypospadias along with extensive dissection to correct chordee and urethroplasty by using local skin flaps, skin graft patches, or island flaps.
• 54332 (1-stage proximal penile or penoscrotal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap).
• 54336 (1-stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap, (use for Duckett repair)). Note: You may see your urologist refer to this procedure as a “Duckett” repair.

Coding tip: When you look at the above the initial, single-stage repair codes, you will notice that they differ based upon the surgical components of the procedure your urologist performs, along with the anatomical location of the repair. For example, you should report codes 54322-54328 for distal repairs. You should report code 54332 for proximal penile or penoscrotal repairs. Lastly, you should report code 54336 for perineal repairs.

Tip 4: See How to Report Multi-Stage, Initial Repair

When the hypospadias opening is far back in the perineum and the tissues of the penis are congenitally of poor quality, to ensure better healing and avoid complications from developing, your urologist may choose to perform an initial multi-stage hypospadias repair, Ferragamo explains. In this case, your urologist would perform one of the following different stages in the repair:

Stage 1: For the first stage of a staged procedure, you can report one of the following codes:

• 54300 (Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra). Note: Code 54300 may or may not include mobilization of the urethra.
• 54304 (Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce and/or skin flaps)

Stage 2: For the second stage of a multi-stage repair, you can choose from the following codes:

• 54308 (Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm) or 54312 (... greater than 3 cm). Note: The differences between codes 54308 and 54312 lie within the size of the repair. You should report 54308 for a repair less than 3 cm and 54312 for a repair greater than 3cm.
• 54316 (Urethroplasty for second stage hypospadias repair (including urinary diversion) with free skin graft obtained from site other than genitalia).

Remember: Codes 54308, 54312, and 54316 include urinary diversion,

Stage 3: If your urologist performs the third stage of a multi-stage repair, you should report code 54318 (Urethroplasty for third stage hypospadias repair to release penis from scrotum [eg, third stage Cecil repair]). Note: Your urologist may refer to a 54318 service as a “Cecil” repair.