Urology Coding Alert

Question: One of my urologists did a perineal exploration and excision of perineal mass. I have looked, but I can't find any codes for this.

Florida Subscriber Answer: There are few CPT codes addressing the perineum, and most of them are concerned with female pathology. If the perineal mass represents a urethral diverticulum in a male patient, you should report codes 53235 (Excision of urethral diverticulum [separate procedure]; male). If in fact this was the excision of a Cowper's gland or a similarly placed cystic structure, you should use 53250 (Excision of bulbourethral gland [Cowper's gland]).

For the exploration of a nondescript perineal mass, look at code 27047 (Excision, tumor, pelvis and hip area; subcutaneous tissue) or 27048 (... deep, subfascial, intramuscular) depending on its location. In this particular anatomy, the pelvic area includes and encompasses the perineum. - Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, New York; and Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 19-urologist practice in Indianapolis.