Wiki 54150 vs. 54161

[lckross]

The below was coded as circumcision using a clamp, 54150; however, the physician is questioning this and wants to use 54161, stating he is doing more work than is involved in 54150 as the phimosis was severe and the foreskin would not readily retract. I would appreciate any insight as to what separates these two procedures beyond use of a clamp-like device?

"The severe phimosis was seen and we attempted to retract the foreskin; however, due to severe phimosis, we were unable to. We proceeded to perform a dorsal slit. The foreskin was clamped at the 12 o'clock position and divided. This allowed for retraction of the foreskin. We then performed a circumcising incision at the preputial skin proximal to the corona as well as the foreskin. The skin was removed with a combination of blunt and sharp dissection as well as the electrocautery was used for hemostasis. The foreskin was completely freed and removed."

Thanks in advance.

 

[liqgold2@aol.com]

Based on the operative report provided, I would suggest CPT code 54161 as the correct code.

 

[liqgold2@aol.com]

As a point of interest per CPT rule: If two procedures are used to accomplish a desired result, bill the one procedure alone of the two that most accomplishes the desired result.