removal of foreign object genitalia- No Incision? CPT Code or included in E/M?

[DAWNC34]

12 yo male with a history of a foreign body on the penis. His penis was stuck within a shampoo bottle. We could not remove this in the ER so he was taken to the OR.
Patient placed under anesthesia without incident. IV clindamycin was given due to a MRSA history. A timeout was performed after the patient was prepped and draped.
A malleable was placed under the foreign body to protect the penile skin. We then used a combination of scissors and a scalpel to cut the shampoo bottle. Once removed the penis was examined. There was significant distal penile edema but the skin was intact and no injuries were noted. The urethra was probed with a foley and no injury was noted.
We then applied Vaseline and extubated the patient without incident.

is there a CPT Code or included work in E/M?
Help!

 

[twizzle]

Almost fits the description of 'you can't fit a square peg in a round hole'.

 

[SharonCollachi]

You went to the OR. Now this isn't my area, but I don't see how it COULD be included in an E&M code. I would think an unlisted procedure code.

 

[liqgold2@aol.com]

In the past I have reviewed this scenario several times. My findings were always...there are no CPT codes to describe this procedure, and there are no codes even to bench mark this foreign body removal. I would suggest using the unlisted code 55899 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 the carrier a suitable fee based on the time spent in the OR and expected postoperative care.
Michael A. Ferragamo MD, FACS, coding and reimbursement consultant for urology

 

[KatrinaKritikos]

In this instance, would CPT 55120 be appropriate since no incision was made

 

[KatrinaKritikos]

In the past I have reviewed this scenario several times. My findings were always...there are no CPT codes to describe this procedure, and there are no codes even to bench mark this foreign body removal. I would suggest using the unlisted code 55899 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 the carrier a suitable fee based on the time spent in the OR and expected postoperative care.
Michael A. Ferragamo MD, FACS, coding and reimbursement consultant for urology

Would 55120 be appropriate in this case even if an incision was not made?

 

[csperoni]

View attachment 7478
Would 55120 be appropriate in this case even if an incision was not made?

Not my area of expertise, but is this situation that the provider removed a BULLET from the SCROTUM without making any incision? If so, I would consider 55120-52 or unlisted, leaning toward unlisted.