Urology Coding Alert

Question: My urologist performed a procedure on a patient for "release of hidden penis." In doing this procedure the physician performed a surgical skin release of the buried penis as well as removal of scar tissue from the exposed penile shaft, a split-thickness skin graft to cover the exposed shaft of the freed penis, a "Z" plasty closure of the released scrotal skin, and a cystoscopic examination. How should I report this procedure? Is an unlisted code appropriate?

Virginia Subscriber

Answer: You should start by reporting 15120 (Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children [except 15050]) and 15004 (Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar [including subcutaneous tissues], or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children) for the split-thickness skin graft and the surgical preparation of the site with excision of scar tissue from the penile shaft.

Next, report 14040 (Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less) for the procedure needed to free the penis and reconstitute the surrounding scrotal skin at the base of the newly freed and covered penile shaft. While there is no code that specifically refers to the surgical treatment of a hidden penis, the urologist basically rearranges the skin surrounding the penis, so 14040 is an appropriate code. You do not need to use an unlisted 55899 (Unlisted procedure, male genital system) code.

Finally, report 52000 (Cystourethroscopy [separate procedure]) for the cystoscopy.

Modifier help: You may need to add modifier 51 (Multiple procedures) to the second, third, and fourth codes if you are reporting the procedures to a payer other than Medicare. Many payers no longer require modifier 51. Processing claims electronically allows the payer to recognize when your physician performs multiple procedures and automatically makes the necessary reduction in payment. Check with your payer to see if you need to use modifier 51 when your urologist performs more than one procedure in a session.