Pediatric Coding Alert

Question: Our pediatrician performed a lysis of adhesions for a patient who had a previous incomplete circumcision. Do I report that with 54162?

South Carolina Subscriber  

Answer: If the procedure does not involve instrumentation and regional anesthesia, and your pediatrician is able to release the adhesions by simply manipulating the patient’s foreskin, then you should report an evaluation and management code (E/M) from 99201-99215.

If the provider manipulates a patient’s foreskin that is creating problems because it is still partially adhered to the patient’s penis, but again no instrumentation or anesthesia is involved, you could report 54450 (Foreskin manipulation including lysis of preputial adhesions and stretching). This is typically performed on patients over the age of 7.

However, if the provider has documented using instrumentation and topical or regional anesthesia beforehand as part of the adhesion removal, then you can certainly report 54162 (Lysis or excision of penile post-circumcision adhesions).

Pro coding tip: If your pediatrician has performed the adhesion removal to repair the incomplete circumcision, then you should report 54163 (Repair incomplete circumcision) only, and not report both codes with modifier 59 (Distinct procedural service) appended. That’s because the lysis is regarded as bundled into the repair — the adhesion removal helps prepare the area around the foreskin for the repair — and so cannot be reported separately.