Urology Coding Alert

Question: My doctor performed lysis of penile adhesions on a patient that is not circumcised. I am not sure what code I should use in this case. Here are the notes:

“Patient was brought to the operating room and placed in the supine position. After monitored anesthesia care, the patient’s groin and perineum were prepped and draped in normal surgical sterile fashion. Retraction of foreskin showed a phimotic foreskin and penile adhesion anterior to the coronal ridge. This was unable to be manipulated and lysed manually. Utilizing Metzenbaum scissors, a plane was created between the foreskin and the corona with great care. This took two times the amount of time typically spent for penile lysis of adhesion. Once a plane was developed, the coronal ridge was identified and developed.  The smegma was removed, and Hibiclens was utilized to clean. Mosquito forceps were utilized to spread and establish the true plane of the foreskin and the glans. The patient tolerated the procedure well without difficulty.”

How should I report this?

Wisconsin Subscriber

Answer: Report 54450 (Foreskin manipulation including lysis of preputial adhesions and stretching) for this clinical scenario. 

Bonus: If you feel that your urologist should be paid more for the extra time spent, add modifier 22 (Increased procedural services) and send the operative report and a supporting letter indicating what the urologist did in layman’s terms and how much more you wish to be paid. Consider asking for double the normal fee since the procedure took twice as long to perform as per the operative note.

As the American Medical Association’s CPT® Changes from 2008 explains, “This modifier should be used only when additional work factors requiring the physician’s technical skill involve significantly increased physician work, time, and complexity than when the procedure is normally performed.”