Urology Coding Alert

Question: How should I code the following procedure:

The patient was brought to the operating suite, placed in supine position, and during the preparation for a total hip resection, the foreskin was retracted, and there were several attempts to insert a Foley catheter by the nursing staff. Because of meatal stenosis, they were unable to get a catheter in. At this time, the penis became edematous and the patient developed a paraphimosis. They were unable to get the foreskin back over the glans penis; therefore urology was called. I examined the patient and attempted to reduce the paraphimosis, but I was unable to because of the amount of edema. At this point, we injected some 1% lidocaine at 12 o’clock, just under the skin and made a 1 cm skin incision to the band of the paraphimotic skin. This was then closed in a Heineke-Mikulicz type fashion with a running chromic. We were then able to easily reduce the paraphimosis. At this point, we then easily inserted a 16-French Foley catheter. I was able to get this into the bladder, and we did obtain some clear urine. He tolerated this well. No complications. I have instructed the other surgeon to just have the patient apply some antibiotic ointment to the foreskin and follow up to see me in the office after discharge.

Lousiana Subscriber

Answer: First, report 54001 (Slitting of prepuce, dorsal or lateral [separate procedure]; except newborn) for the dorsal slit in the retracted foreskin for the paraphimosis. Use ICD-9 code 605 (Redundant prepuce and phimosis [ICD-10 code: a more specific code from the N47.0-N47.8 range]) with 54001.

Beware: The reduction of the paraphimosis (54450, Foreskin manipulation including lysis of preputial adhesions and stretching) and the insertion of the Foley catheter (51702, Insertion of temporary indwelling bladder catheter; simple [eg, Foley]) are bundled into the 54001 and consequently cannot be billed as separate services.

There is little documentation in the medical records supplied for billing an intraoperative consultation (99251-99255, Inpatient consultation for a new or established patient ...). An intraoperative consultation should be documented on a separate sheet indicating a separate service from the operative procedures. Therefore, you should not report an intraoperative consult under the above clinical circumstances due to insufficient documentation.