Urology Coding Alert

Question: The patient is a 12-year-old boy with a history of a foreign body on the penis. His penis was stuck within a shampoo bottle. The urologist could not remove this in the emergency room (ER), so he was taken to the operating room (OR). The patient was placed under anesthesia without incident. He was given intravenous (IV) clindamycin due to a methicillin-resistant Staphylococcus aureus (MRSA) history. The urologist performed a timeout after the patient was prepped and draped. The urologist then placed a malleable under the foreign body to protect the penile skin. My urologist used a combination of scissors and a scalpel to cut the shampoo bottle. Once removed, my urologist examined the penis There was significant distal penile edema, but the skin was intact, and no injuries were noted. My urologist probed the urethra with a Foley, and no injury was noted. My urologist then applied Vaseline and extubated the patient without incident. Is there a CPT^® code for this service or is the work included in the evaluation and management (E/M) service?

AAPC Forum Subscriber

Answer: There are no CPT^® codes to describe this procedure, and there are no codes to even benchmark the foreign body removal (FBR). You should report unlisted code 55899 (Unlisted procedure, male genital system) and present the carrier with a detailed operative report explaining what was done and the time spent in removing the foreign body from the penis. Give your carrier a suitable fee based on the time spent in the OR and expected postoperative care.