The physician would like to bill 54450, manipulation of foreskin, for the procedure described below. I don't think there is enough documentation to justify billing this code. Also, the following day's progress note states "the patient felt better after foreskin dilation yesterday." Thoughts? Thank you!!
HISTORY OF PRESENT ILLNESS:
The patient is a 73-year-old male with difficulty voiding. The patient is status post radiation seed implants many years ago for prostate cancer. Over the past 10 years however, he has had increasing difficulty retracting his foreskin and has been able to do so at least for the past 8 years. He began to note increasing difficulty voiding with severe postop dribbling. This intensified last week and he was seen in the emergency room where he was noted to have a severely scarred foreskin. He was discharged home since he was able to void in the ER; however, re-presented with difficulty voiding again. When he voids, he notices constant dribbling. A bladder scan performed showed 390 mL. He denies any irritative symptoms.
PAST MEDICAL HISTORY:
Positive for asthma, hypertension, prostate cancer, sarcoid, atrial fibrillation, and DVT.
PHYSICAL EXAMINATION:
GENERAL: He is a well-nourished male, comfortably sitting in bed.
HEENT: Normal.
LUNGS: Clear.
COR: S1 and S2 normal.
ABDOMEN: Benign, nontender. No bladder tenderness or distention.
NEUROLOGICAL: Grossly normal.
DIAGNOSTIC IMPRESSION:
1. Severe phimosis, secondary to chronic scarring.
2. Difficulty voiding, secondary to severe phimosis.
PROCEDURE:
An attempt was made to gently dilate the foreskin. However, due to the severe scarring, it was impossible to find his meatus. Therefore, this approach was abandoned.
RECOMMENDATIONS:
The patient will require a suprapubic tube by Invasive Radiology, and he will probably require outpatient circumcision.
HISTORY OF PRESENT ILLNESS:
The patient is a 73-year-old male with difficulty voiding. The patient is status post radiation seed implants many years ago for prostate cancer. Over the past 10 years however, he has had increasing difficulty retracting his foreskin and has been able to do so at least for the past 8 years. He began to note increasing difficulty voiding with severe postop dribbling. This intensified last week and he was seen in the emergency room where he was noted to have a severely scarred foreskin. He was discharged home since he was able to void in the ER; however, re-presented with difficulty voiding again. When he voids, he notices constant dribbling. A bladder scan performed showed 390 mL. He denies any irritative symptoms.
PAST MEDICAL HISTORY:
Positive for asthma, hypertension, prostate cancer, sarcoid, atrial fibrillation, and DVT.
PHYSICAL EXAMINATION:
GENERAL: He is a well-nourished male, comfortably sitting in bed.
HEENT: Normal.
LUNGS: Clear.
COR: S1 and S2 normal.
ABDOMEN: Benign, nontender. No bladder tenderness or distention.
NEUROLOGICAL: Grossly normal.
DIAGNOSTIC IMPRESSION:
1. Severe phimosis, secondary to chronic scarring.
2. Difficulty voiding, secondary to severe phimosis.
PROCEDURE:
An attempt was made to gently dilate the foreskin. However, due to the severe scarring, it was impossible to find his meatus. Therefore, this approach was abandoned.
RECOMMENDATIONS:
The patient will require a suprapubic tube by Invasive Radiology, and he will probably require outpatient circumcision.
