Urology Coding Alert

Hint: Not all three codes are appropriate for most cases -- find out why.

If you code for pediatric urologists, you may see a fair share of hypospadias repair procedures cross your desk. Coding for these procedures can pose a challenge to even seasoned coders.

For example: Do you know whether you should report more than one code to accurately describe the procedure? See how your coding stacks up with the experts' by testing your hand at coding this case study from Becky Boone, CPC, CUC, certified reimbursement assistant for the University of Missouri Department of Surgery in Columbia.

Review the Surgical Case

Preoperative diagnosis: Distal hypospadias

Postoperative diagnosis: Distal hypospadias

Procedure:

Distal hypospadias repair

Byers flap

Dorsal only flap

Indication for Procedure:

This is a 7-year-old male with history of distal hypospadias. The family was advised many years ago to have this repaired under anesthesia. However, they were lost to follow-up and did not return for evaluation until the child was much older. They now request that his hypospadias be corrected surgically. The risks and benefits of surgery were explained at length to the patient's family, and they agreed to proceed.

Description of Procedure:

The patient was brought to the operative suite and placed on the OR table in the supine position. After adequate general endotracheal anesthesia was performed by the anesthesiologist, the patient's genitalia were then prepped and draped in the usual sterile fashion. A holding suture was placed through the glans for retraction. The urethral meatus was somewhat narrow in a subcoronal location. This would dilate up to 8 French, and therefore, part of the lip of the meatus was cut back using a Westcott scissors, and the skin edges were reapproximated using interrupted 7-0 PDS. This now calibrated up to 12 French easily. Holding sutures were placed in the dorsal hooded foreskin. A marking pen was used to mark out the glans collar, and this was brought around ventrally proximal to the urethral meatus. The skin was then incised using a scalpel. The penile shaft skin was then carefully degloved using sharp dissection as well as Bovie cautery for hemostasis. After all the chordee elements were taken down, there was no evidence of any penile curvature. At this point, a vascularized pedicle flap was harvested from the dorsal preputial skin and brought around ventrally through a buttonhole at the base of the pedicle. This would be used later for coverage of the repair. A tourniquet was then placed at the base of the penis for hemostasis. A marking pen was used to mark out the urethral plate on either side of the glans. This was incised deeply with a Beaver blade scalpel. The glans wings were then further developed using a Westcott scissors. Hemostasis was achieved. The urethral plate was then incised deeply in the midline in order to hinge the plate and to allow tubularization of the urethra without tension. The urethra was then tubularized over a 10-French bougie using running PDS suture for a first layer and then interrupted 7-0 PDS for a second layer. The dorsal pedicle flap was then laid over the repair for a third layer of coverage. Hemostasis was then obtained. The glans was then reconstructed in multiple layers using interrupted 6-0 PDS sutures. The edges of the glans collar were trimmed appropriately. The tourniquet was then released, and hemostasis was excellent. There was not sufficient ventral penile shaft skin for coverage, and therefore, Byers flaps were created using dorsal and lateral skin, and less than 10 sq cm of skin coverage was created by interdigitating the skin edges ventrally with interrupted 6-0 PDS suture. The excess foreskin was then removed, and the 10-French Zaontz urethral catheter was then placed per urethra and anchored to the glans using a 5-0 Prolene suture. A sterile dressing was applied. The patient tolerated the procedure well, and he was then transported to the recovery room in stable condition.

Coding dilemma: How would you code this procedure?

"For this case, my group of pediatric urologists want to bill the following codes together: 54324, 15740, and 14040," Boone says. "They state that they've been to conferences where they are being told that this is appropriate, but I have never coded this way. Can I actually report all three codes for this case and others like it?"

No CCI Bundle Isn't a Green Light for Additional Coding

When you are considering reporting multiple procedure codes for a surgical encounter, one of the first places you probably should look is at the Correct Coding Initiative (CCI) edits. There are no CCI edit bundling for any of the following codes:

• 54324 -- 1-stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps (eg, flip-flap, prepucial flap)
• 15740 -- Flap; island pedicle
• 14040 -- Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less.

Caution: "But just because there is no CCI edit saying you cannot report these codes together, doesn't mean you can just automatically report all three codes," warns Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook.

Pay Attention to the Code Descriptors

There are other types of bundlings as well that you need to consider. In this case, you should consider what is included in the procedure as noted by the actual description of 54324.

How it works: "15740 describes a flap or island pedicle. 14040 is adjacent tissue transfer," explains Jonathan Rubenstein, MD, director of coding and physician compliance for Chesapeake Urology Associates in Baltimore. "52324 describes a 1-stage hypospadias repair and it says it includes local skin flaps as part of its description. So I don't think that it is appropriate to bill 14040 or 15740 separately as they seem to be included in the description of the procedure."

Look at similar codes: There are other codes that are similar in terms of the description of local skin flaps and adjacent tissue transfer being part of the main procedure code. For urethral mobilization with flap or tissue transfer, you would just code 54326 (1-stage distal hypospadias repair [with or without chordee or circumcision]; with urethroplasty by local skin flaps and mobilization of urethra), Rubenstein explains.

If your urologist truly performs hypospadias repair along with an island flap, it would be more appropriate to report 54328 (1-stage distal hypospadias repair [with or without chordee or circumcision]; with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/or island flap) than 54324 and 15740, Rubenstein says.

Final Coding: Pick Just One

The bottom line is that for procedures such as the one described in this case study reporting 54324 alone is really the most appropriate billing just as we suspected from our earlier discussions.

Consult your urologist: In reality, your urologist can bill all three codes if he truly believes all three best represent the surgery he performed. There is no CCI edit or other specific guideline that states you cannot report all three. "They can bill whatever they want," Ferragamo says. "That doesn't mean it is necessarily proper coding, and I don't think what they did in the procedures supports coding anything other than 54324. If a payer asks to review the op report, they probably would agree that the documentation does not support more than code 54324."