Urology Coding Alert
Fix Fracture Repair Coding with 54440
Question: How do I code this op report: “The penis was degloved, and we noticed he had a very large hematoma on the right side of the penis. This hematoma was just above the penile scrotal junction. As we explored this area, we were able to evacuate his hematoma. We then were able to find the areas of concern on the corporal body. These edges were cleaned up, and then the corporal fracture was then closed with vicryl interrupted sutures x 6. After closing the injury of the corporal body, we injected saline to create an artificial erection to demonstrate no evidence of leakage from corporal repair. We removed the injection needle and irrigated and evacuated the rest of the hematoma. We then re-approximated the penile skin using 3-0 chromic sutures.”?
Codify Forum Member
Answer: This clinical scenario represents a traumatic “fracture” of the penis, which you’ll report with ICD-9 diagnosis 959.13 (Fracture of corpus cavernosum penis) [ICD-10: S39.840A].
For the repair of this injury as described above, use 54440 (Plastic operation of penis for injury).
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