Bridge the Gap With This Penile Procedure
Question: A 28-year-old patient came to the office describing a painful tugging sensation whenever they experienced an erection. After a brief history and physical exam, the urologist noticed that skin bridges were present near the site of their original circumcision. The patient confirmed they were circumcised as an infant. The urologist then performed a surgical removal of the skin bridges located at the frenulum and dorsal side of the patient. How should I report the skin bridge removal? North Dakota Subscriber Answer: For the skin bridge removal procedure, 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. Skin bridge defined: A penile skin bridge is a condition where the skin from the penis shaft sticks to the round border near the penis tip, known as the coronal margin. This can occur due to improper healing post-circumcision or because of friction and moisture in the diaper area in infants. This is a more lasting form of adhesion compared to other types like glanular adhesions, which are usually minor and often resolve without intervention. Make note: Verify with the practitioner to confirm the lysis procedure involved the use of instruments and general anesthesia before coding for 54162. If the urologist was able to manually dissolve the post-circumcision adhesions without the need for an instrument to sever the adhesions, then you should not use 54162. Instead, an appropriate evaluation and management (E/M) code should be selected instead. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
