Wiki Circumsision with release of frenulu adhesions

[dkanewi1]

Patient comes in with frenulum adhesions and redundant foreskin (had prior circ). Provider does a release of the frenulum adhesions and performs a 2nd circ per his notes.

Provider wants to bill this as 54162-59 and 54161 or would this be more appropriate with just the 54161?

 

[FTessaBartels]

Patient under general anesthesia?

Urology is NOT my specialty, but

CPT 54162 - per Encoder Pro
The physician retracts the foreskin, releases the preputial post-circumcision adhesions, and cleanses the glans in a patient who is under general anesthesia. If retraction of the foreskin reveals a fibrous ring, the physician places two vertical incisions directly over the fibrous ring and the transversely running fibrous bands are divided to expose the underlying Bucks' fascia. With the foreskin retracted, the defect is closed horizontally with interrupted sutures. (emphasis added by FTB)

It looks to me that 54162 and 54161 are bundled, but can be reported together with use of modifier. However, ONLY if done under general anesthesia ...

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[adebenham]

If the patient was not put under general anthesthesia just localized anthesthesia would there be a different code used or would a modifer 52 work?

 

[FTessaBartels]

No general anesthesia = E/M code

You would just code the documented E/M visit

Hope that helps.

F Tessa Bartels, CPC, CEMC