Circumcision revison and Z-Plasty


Mckinleyville, CA
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I need help on this one, because I'm not really sure which code to use. I was thinking possibly 54163, but doc says 54001, and I'm not really very familiar with these codes at all, so any help is Greatly appreciated!

Here's the op note in part: ....He had significant phimosis. A dorsal and ventral slit was done in order to allow enough space for the glans to be uncovered. The glans and the surrounding tissue was prepped, again, with povidon-iodine. On the dorsal surface, by doing the longitudinal slit, we now had an opportunity to add about 1cm to the circumference of the penile skin by doing a horizontal closure of his vertical slit; this was done with 5-0chromic. On the ventral surface of the penis he still had his longitudinal slit, but instead we fashioned a Z-plasty and swung a flap from posterolateral into this area so that we would not have a longitudinal or two vertical incisions. This gave us a Z-plasty scar on the bottom of the penis, which would be much better for him. Therefore, this was closed with a 5-0 chromic as well. No actual skin was removed. By doing what we did and releasing the skin, we incorporated the skin that had been part of his phimosis into the penile coverage. All skin was viable including the Z-plasty. His penis was now uncovered from the scrotum and there was no phimosis.

Thank you for your help!!!