Question 54164 or 54163?

toria11

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Hi! Would you code this as 54164 or 54163? Thanks!!

Indication for operation: Excess foreskin at the frenulum. 48 yo male s/p circumcision in 2016, who c/o excess skin ventrally. It is causing intermittent pain/burning sensation. It is bothersome with intercourse
Preoperative diagnosis: Excess foreskin
Findings: Excess foreskin at the frenulum
Specimens: None
Operation performed: Revision of circumcision/frenuloplasty
Description of operation: After informed consent was obtained, the patient was brought back to
operating room and underwent general LMA anesthesia. His genitalia was prepped and draped
in a sterile surgical manner. A time-out was performed
A penile block was performed using 0.25 percent Marcaine plain. The excess foreskin at the
frenulum was then excised. Hemostasis was obtained. The skin edges were then
reapproximated using 4-0 chromic in a running fashion. Sterile dressings then applied. Patient
was then taken to recovery room in stable condition. RM 20211207
 
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