Urology Coding Alert

Focus on initial versus complication first.

When your urologist performs a hypospadias repair procedure on a pediatric patient, there are several codes that could apply, which makes your job a challenge. 

You’ll start by determining if your urologist is performing an initial repair (54300-54336), a repair of complications (54340-54348), or a repair of a hypospadias cripple (54352). Read on to ensure you know which code set to turn to when coding your urologist’s procedures. 

1. Focus on Staging and Meatus Location for Initial Procedures

“For hypospadias repairs, the code you use is based on the location of the meatus, what you do surgically, and how many stages will be required to complete the repair,” explains Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook. 

Multi-stage: Once you know your urologist is performing an initial hypospadias repair, you need to scour the documentation to see if he performed a staged procedure. For the first stage of a staged procedure, you’ll report one of the following:

• 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.

For the second stage, choose from the following codes, based on the repair size:

• 54308 — Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm

• 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.

Finally, if your urologist performs a third stage, report 54318 (Urethroplasty for third stage hypospadias repair to release penis from scrotum [eg, third stage Cecil repair]).

Single stage: If your urologist notes that he performed a 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)

These codes differ based on the surgical components of the procedure as noted in the code descriptors as well as the anatomical location of the repair, Ferragamo says. You’ll use 54322 or 54324 for distal repairs, and 54324, 54326, or 52348 for mid-shaft repairs, he adds. Apply 54332 for proximal penile or penoscrotal repairs and 54336 for perineal repair.

2. Switch Code sets for Complication Repair

If your urologist is repairing a complication from a previous hypospadias repair, such as a stricture or fistula, you won’t use the codes listed above. Instead, choose from one of the following, based on the complexity of the repair:

• 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).

Exception: If your urologist notes he performed a “repair of a hypospadias cripple,” 54340-54348 don’t apply. Rather, you’ll report 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). 

3. Watch For Additional Reportable Procedures

Note that the hypospadias repair codes include many of the component procedures that your urologist may also perform in the same surgical session, and you should not separately report those procedures. For example, if your urologist performs a “Nesbitt procedure,” which is a plastic repair of the penis to correct angulation, you should not separately report 54360 (Plastic operation on penis to correct angulation) along with the hypospadias repair code.

There are some procedures that are not included in the primary hypospadias repair codes. For example, if your urologist performs a tunica vaginalis graft for urethroplasty coverage, you can separately report 15740 (Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel) with primary codes 54324, 54326, 54328, 54332, and 54336. However, if he performs a Dartos island flap, you should not separately report 51740 with mid-shaft and proximal hypospadias repair codes 54328, 54332, or 54336, Ferragamo warns.  

See the box on the right for other procedure codes your urologist may perform. You’ll need to check with your payer to see if you can separately bill for any of the listed procedures.

Additionally: If your urologist has to perform extensive reconfiguration of Byar’s flaps or a scrotal flap to cover the urethroplasty, you should report 14040 (Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less) with the hypospadias repair code. For harvesting a buccal graft, report 15240 (Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less) and 15120 (Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children [except 15050]) for a split thickness graft. 

Example: Your urologist is treating a patient with a mid-shaft penile hypospadias and chordee. He performs a one-stage initial repair with extensive straightening of the chordee, local skin flaps, a buccal mucosal tube urethroplasty, and an artificial erection to gauge the degree of chordee. You should report 54328 for the hypospadias repair. Then, report 15240 for the graft and 54235 (Injection of corpora cavernosa with pharmacologic agent[s] [eg, papaverine, phentolamine]) for the induced artificial erection during the procedure. Attach modifier 51 (Multiple procedures) to 15240 and 54235 if your payer requires that modifier. You will use ICD-9 code 752.61 (Hypospadias).