Urology Coding Alert

Question: Following trauma to the scrotum and penis the urologist performed a scrotal and penile exploration with evacuation of a large penile hematoma. I've never had to code a penile hematoma evacuation before. Would the I & D code CPT 54015 be most appropriate? Is the exploration included in the evacuation code?Answer: You'll need to refer to your urologist's documentation to decide the proper code for the hematoma evacuation. Ask yourself: Was the hematoma superficial, involving the subcutaneous tissues above Buck's fascia, or involving the deeper tunica and surrounding tissues?Report 10140 (Incision and drainage of hematoma, seroma, or fluid collection) for a superficial hematoma. For a deeper collection of blood (hematoma), report 54015 (Incision and drainage of penis, deep). Base your decision and choice of CPT code on the operative documentation.Tip: If your urologist incises just the skin, 10140 would seem most appropriate. If he instead goes through to deeper [...]