I'm new to a group of peds urologists who did not previously have a coder. I still have a poor understanding. My providers are trying to bill 14040 when mucosal collar flaps are mobilized along with angulation correction. Is the work described even separately billable? I'm having a hard time finding this info.
Below is the description of the procedure. Provider billed 54360, 54161, 14040.
After obtaining informed consent from his mother, satisfactory general anesthesia was obtained. Lower abdomen, groin, and genitalia were prepped and draped in the usual sterile fashion after a caudal block was administered. The phimosis was relieved, adhesions were lysed. A suture was passed through the glans and used for retraction. An incision was made 5 mm from the sulcus on mucosal collar swinging on either side laterally, leaving mucosal collar flaps and continued in an inverted V shape fashion ventrally to the level of the glans to resect his tight frenulum and the redundant mucosal collar tissue. The dissection proceeded down to the Buck's fascia and his penis was degloved to the base. All dysgenic bands contributing to the penile angulation were released. Nonetheless, artificial erection revealed persistent ventral angulation, which was repaired with dorsal plications of 6-0 PDS. Once his penis was straightened, an outer circumferential incision was made and the redundant foreskin was removed. The mucosal collar flaps were mobilized in midline and brought together with interrupted 5-0 chromics for repair. The circumcision line was closed with interrupted 5-0 chromics tacking it down to the Buck's fascia in multiple locations to repair his hidden penis as well. Hemostasis was assured, ointment was applied, and he was awakened in the Operating Room, having tolerated the procedure with no known complication.
They are actually billing 14040 with all repair surgeries and we are trying gather some info for them. We know size of defects is a requirement per CPT manual, just trying to figure out what work is billable. The main information that I have is when 14040 is billable in the context of hypospadias repair.
Any and all help is much appreciated.
Below is the description of the procedure. Provider billed 54360, 54161, 14040.
After obtaining informed consent from his mother, satisfactory general anesthesia was obtained. Lower abdomen, groin, and genitalia were prepped and draped in the usual sterile fashion after a caudal block was administered. The phimosis was relieved, adhesions were lysed. A suture was passed through the glans and used for retraction. An incision was made 5 mm from the sulcus on mucosal collar swinging on either side laterally, leaving mucosal collar flaps and continued in an inverted V shape fashion ventrally to the level of the glans to resect his tight frenulum and the redundant mucosal collar tissue. The dissection proceeded down to the Buck's fascia and his penis was degloved to the base. All dysgenic bands contributing to the penile angulation were released. Nonetheless, artificial erection revealed persistent ventral angulation, which was repaired with dorsal plications of 6-0 PDS. Once his penis was straightened, an outer circumferential incision was made and the redundant foreskin was removed. The mucosal collar flaps were mobilized in midline and brought together with interrupted 5-0 chromics for repair. The circumcision line was closed with interrupted 5-0 chromics tacking it down to the Buck's fascia in multiple locations to repair his hidden penis as well. Hemostasis was assured, ointment was applied, and he was awakened in the Operating Room, having tolerated the procedure with no known complication.
They are actually billing 14040 with all repair surgeries and we are trying gather some info for them. We know size of defects is a requirement per CPT manual, just trying to figure out what work is billable. The main information that I have is when 14040 is billable in the context of hypospadias repair.
Any and all help is much appreciated.