Urology Coding Alert

Question: Following trauma to the scrotum and penis the urologist performed a scrotal and penile exploration with evacuation of a large penile hematoma. I’ve never had to code a penile hematoma evacuation before. Would the I&D code 54015 be most appropriate? Is the exploration included in the evacuation code?

Montana Subscriber

Answer: You’ll need to refer to your urologist’s documentation to decide the proper code for the hematoma evacuation. Ask yourself: Was the hematoma superficial, involving the subcutaneous tissues above Buck’s fascia, or involving the deeper tunica and surrounding tissues?

Report 10140 (Incision and drainage of hematoma, seroma or fluid collection) for a superficial hematoma. For a deeper collection of blood (hematoma), report 54015 (Incision and drainage of penis, deep). Base your decision and choice of CPT^® code on the operative documentation.

Tip:  If your urologist incises just the skin, 10140 would seem most appropriate. If he instead goes through to deeper tissues, 54015 would be most appropriate.

Additionally: The Correct Coding Initiative (CCI) does not bundle 55110 (Scrotal exploration) with either 54015 or 10140. This makes sense since your urologist was looking at different body areas-- the penis and scrotum. Therefore, you may separately report the scrotal exploration in addition to and along with one of the above-mentioned CPT^® codes.