Penile Exam under Anesthesia

Jessim929

Guru
Messages
178
Best answers
0
This one is a first for me.

Patient seen one day post-circumcision by an out of state doctor. Had penile hematoma. My doctor took the patient to the OR, expecting to repair the circ. Instead found that "the penis had no penile skin and the bottom of the corona was sutured to the upper edge of the scrotal skin. The shaft is palpable but unexposed and if I released the sutures I would be facing a degloved penis that would need a skin graft so I left the sutures in place and decided not to intervene at this time."

Is there even a code for this? Or do I do E&M?

Thank you!!
 
Messages
193
Best answers
0
Since your urologist is unrelated and not an associate to the surgeon having performed the circumcision, no modifier is needed on the visit code.
 

LisaAlonso23

Expert
Messages
447
Location
Sherman, TX
Best answers
0
If the patient was not put under prior to receiving anesthesia, then an E/M would be appropriate.

Being that the patient was under anesthesia (as stated in the headline of this post), billing an E/M would not be appropriate if the procedure was aborted after the patient was put under. Bill the procedure intended with a 53 modifier that indicates the procedure was aborted. If you bill an E/M, the anesthesiologist cannot justify his/her claim as we provide anesthesia services for those codes.
 
Messages
193
Best answers
0
Interesting comments from an anesthesiologist's point of view and billing perspective. Thank you Lisa for your comments, and I would agree so that the anesthesiologist may bill and also be paid for his services. Therefore, I would suggest 54163-53 for the procedure terminated.
 
Top