Urology Coding Alert

Hint: Differentiate between initial repair versus repair of complication.

If your urologist performs a hypospadias repair for a pediatric patient, you must look for important details in the documentation when choosing the appropriate codes for your claim including the location of the meatus, what your urologist does surgically, and how many stages it takes him to complete the repair.

Follow these five rules to always submit clean hypospadias repair claims in your urology practice.

Rule 1: Understand Hypospadias for Clarity

Hypospadias is a congenital condition in pediatric patients with the urinary meatus (opening) not located at the end of the penis. Instead, the opening of the urethra is on the underside of the penis, anywhere from the distal portion of the penis to the perineal area.

Rule 2: Rely on These Codes for Multi-Stage, Initial Repair

If you check the medical documentation to determine if your urologist performed an initial hypospadias repair, you must also determine if he performed a multi-stage or single stage repair.

In a multi-stage repair, your urologist can perform one of the following three different stages:

Stage 1: For the first stage of a staged procedure, you can report one of the following codes:

• 54300 (Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra)
• 54304 (Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce and/or skin flaps)

Stage 2: For the second stage of a multi-stage repair, you can choose from the following codes:

• 54308 (Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm) or 54312 (... greater than 3 cm)
• 54316 (Urethroplasty for second stage hypospadias repair (including urinary diversion) with free skin graft obtained from site other than genitalia)

Stage 3: If your urologist performs the third stage of a multi-stage repair, you should report code 54318 (Urethroplasty for third stage hypospadias repair to release penis from scrotum [eg, third stage Cecil repair]).

Rule 3: Turn to These Options for Initial Single-Stage Repair

On the other hand, if your urologist performs an initial, single-stage hypospadias repair, you will choose one of the following codes:

• 54322 (1-stage distal hypospadias repair (with or without chordee or circumcision); with simple meatal advancement (eg, Magpi, V-flap))
• 54324 (... with urethroplasty by local skin flaps (eg, flip-flap, prepucial flap), (use for a Mathieu repair))
• 54326 (... with urethroplasty by local skin flaps and mobilization of urethra, (use for Snodgrass/Thiersh repairs))
• 54328 (... with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/or island flap)
• 54332 (1-stage proximal penile or penoscrotal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap)
• 54336 (1-stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap, (use for Duckett repair))

“The initial choice of a single-staged hypospadias repair is based on the location of the hypospadias meatus on the ventral surface of the penis,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, New York.

Remember: As you can see by the above code descriptors the initial, single-stage repair codes differ based upon the surgical components of the procedure that your urologist performs, as well as the anatomical location of the repair.

For example, you should report codes 54322-54328 for distal repairs. You should report code 54332 for proximal penile or penoscrotal repairs. Finally, you should report code 54336 for perineal repairs.

Also, note that certain codes mention specific urologists’ names for repairs. For example, the code descriptor for 54324 specifies a Mathieu repair. The descriptor for 54326 specifies Snodgrass/Thiersh repairs. Also, 54336 specifies a Duckett repair.

Rule 4: Report Complication Repairs Like This

If your urologist must repair a complication from a previous hypospadias repair like a stricture, fistula, or diverticula, you should choose from the following codes:

• 54340 (Repair of hypospadias complications (ie, fistula, stricture, diverticula); by closure, incision, or excision, simple)
• 54344 (... requiring mobilization of skin flaps and urethroplasty with flap or patch graft)
• 54348 (... requiring extensive dissection and urethroplasty with flap, patch or tubed graft (includes urinary diversion).

Don’t miss: However, if your urologist performs a repair of a hypospadias cripple that requires extensive dissection and excision of previously constructed structures, you should look to code 54352 (Repair of hypospadias cripple requiring extensive dissection and excision of previously constructed structures including re-release of chordee and reconstruction of urethra and penis by use of local skin as grafts and island flaps and skin brought in as flaps or grafts).

Rule 5: Remember Correct ICD-10-CM Codes on Claim

When you report a hypospadias repair CPT^® code, don’t forget to link the appropriate ICD-10-CM code on your claim. You will report the ICD-10-CM code based upon the location of the meatus.

Take a look at your ICD-10-CM code choices for hypospadias:

• Q54.0 (Hypospadias, balanic). Note: This code also includes coronal and glandular hypospadias.
• Q54.1 (Hypospadias, penile)
• Q54.2 (Hypospadias, penoscrotal)
• Q54.3 (Hypospadias, perineal)
• Q54.8 (Other hypospadias). Note: This code also includes hypospadias with intersex state.
• Q54.9 (Hypospadias, unspecified) Note: You should not use an unspecified diagnosis if at all possible because many payers will not reimburse for unspecified codes, Ferragamo cautions.