Urology Coding Alert

Question: A 50-year-old male patient has severe phimosis, and my urologist is ruling out carcinoma. My urologist performed a removal of the foreskin mass, a lysis of severe foreskin to glans adhesions, and phalloplasty with circumcision. During the procedure, after successful induction of anesthesia, my urologist sterilely prepped and draped the patient’s penis. My urologist could palpate a 1 cm to 2 cm mass, involving the tip of the foreskin with severe scarring to the underlying glans and meatus. Using careful dissection, my urologist split the foreskin on the dorsal and ventral aspect down to what appeared to be the meatus. The foreskin was totally adhered to the glans at this point. Using combination of blunt and sharp dissection, my urologist carefully dissected the foreskin away from the glans itself until normal tissue was reached. The foreskin showed a hard nodular mass, measuring approximately 1 cm to 2 cm involving the tip of the foreskin. So, my urologist resected this area of the foreskin. Once that was accomplished, my urologist focused on reconstructing the penis. They trimmed the penile skin, eliminating redundant foreskin. Once that was accomplished, my urologist fulgurated all bleeding points. Again, there was severe adherence of the undersurface of the foreskin to the glans. Next, my urologist reapproximated the edges of the skin with interrupted 3-0 chromic catgut sutures. They then fulgurated all bleeding points. The meatus was wide open, so my urologist placed a catheter. They then used Bacitracin and Xeroform dressing, and the patient was taken to the recovery room in good condition, having tolerated the procedure well. Pathological examination revealed acute and chronic inflammation of the foreskin with no evidence of a tumor formation. What procedure code should I report for this case?

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Answer: You should report 54161 (Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age) for circumcision.

Don’t miss: If your urologist needs to report this same procedure on an infant 28 days old or less, you should report 54160 (Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less)).