Urology Coding Alert

Adult or adolescent circumcision is common, but if there is no medical reason for the circumcision the insurance company may not pay. When the circumcision is medically necessary, urology coders must use the appropriate diagnosis code to ensure reimbursement. 

Billing for Medically Necessary Circumcision

The following conditions justify circumcision and will garner payment:
 
1. Phimosis, paraphimosis. For ICD-10, they do not share a diagnosis code. You’ll report a code in the N47 range, based on the type of disorder. Phimosis (605), the most common medical reason for adult circumcision, is billable. This condition occurs when the foreskin is abnormally constricted and can't be pulled back. Use the circumcision code 54161 (Circumcision, surgical excision other than clamp, device or dorsal slit; older than 28 days of age).

Circumcision on a patient with paraphimosis (605) can also be billed. For ICD-10, phimosis and paraphimosisdo not share a diagnosis code. You’ll report a code in the N47 range, based on the type of disorder.  This condition occurs when the foreskin is pulled back and gets trapped, forcing a constricting band that could produce ischemia.

When the diagnosis is paraphimosis, the procedure sometimes involves cutting the band and later performing a circumcision. If there is excess edema, the urologist cuts the band and bills 54001 (Slitting of prepuce, dorsal or lateral [separate procedure]; except newborn). Code 54001 has a zero-day global. The circumcision is usually performed a month later and is billed with 54161.

If the physician performs the circumcision during the same session as the dorsal slit procedure, report only 54161. You cannot bill 54001 and 54161 on the same day. Unbundling of 54001 is never allowed.

2. Cancer. Another medically necessary reason for adult circumcision is cancer of the foreskin (187.1), a type of cancer of the penis.  For ICD-10, report C60.0 (Malignantneoplasm of prepuce). Circumcision is curative. Bill 54161.

3. Condylomata. Condylomata — venereal warts — is also a condition that carriers will reimburse for. Use 078.11 or for ICD-10, report A63.0 (Anogenital [venereal] warts) as the diagnosis, and bill with 54161.

4. Balanitis. An infection of the foreskin, known as balanitis or balanoposthitis (both 607.1), also justifies circumcision. For ICD-10, report N47.6 (Balanoposthitis)or N48.1 (Balanitis).  Use 54161 for the procedure. Because balanitis may be a first sign of diabetes mellitus in older men, urologists conduct a urinalysis (81000) to look for glycosuria (791.5). For ICD-10, report R81.

5. UTI. Sometimes a patient requires a circumcision due to a history of urinary tract infections (UTI). "An inflamed foreskin has been implicated as the cause for urinary infections in boys and young men," notes Michael A. Ferragamo, MD, clinical assistant professor of urology at the State University of New York, Stony Brook. Do not attempt to use UTI as a primary diagnosis for circumcision — it will not be paid. Rather, use 607.1 (balanoposthitis) or for ICD-10, report N47.6 (Balanoposthitis)or N48.1 (Balanitis) as the primary diagnosis, and list the appropriate UTI code as a secondary diagnosis.

Circumcisions That are Not Medically Necessary

Circumcisions for cosmetic or religious reasons are not deemed medically necessary. Under these circumstances, check with the insurance company to see if it will pay. If you have any doubt, warn the patient that the bill will be his responsibility.

Some urologists try to bill a routine circumcision with 605 because it is also the diagnosis code for redundant prepuce — what some urology coders consider to be normal foreskin. But compliance experts stress that you should not bill a routine circumcision with 605.

"'Redundant' doesn't mean normal," explains Susan Callaway, CPC, CCS-P, an independent coding trainer based in Augusta, S.C. "'Redundant' means that it's an overwhelming amount." If you perform a circumcision solely to remove foreskin, do not use 605 as the diagnosis code, it is not accurate. Instead, use V50.2 (Routine or ritual circumcision) or for ICD-10, report Z41.2 (Encounter for routine and ritual male circumcision) and explain to the patient that he is responsible for the bill.

Coding the Counseling

Circumcision counseling can take a long time, and if more than 50 percent of the encounter time is spent on counseling, upcode the E/M level (99201-99205, 99212-99215, 99241-99245) accordingly. Most patients have a lot of questions, and may even change their minds about having the procedure. Meanwhile, you have spent much time explaining it to them. Track your time and bill your consultation at an appropriate level to capture that time.