penile exploration for possible fracture cpt code

cs714

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Patient brought the operating room placed on operating table. After administration of appropriate prep and drape of the lower abdomen penis perineum and anterior thighs a degloving incision was made beginning approximately 1 cm proximal to the corona of the glans penis. Appropriate plane was entered and I was able to degloved the penis back to the deviation of the corpora cavernosa. There was no evidence of defect within the corpora urethra appeared intact. The patient did not have blood at the meatus was able to void immediately post incident and therefore I did not perform cystoscopy. At this point I was careful to look for active bleeding. Not identify any. And the proximal shaft skin was reapproximated to the mucosal skirt using interrupted 3 O chromic suture circumferentially. A light dressing was applied with bacitracin ointment to the incision line patient was taken recovery room stable condition testes

Not sure if its 54440 or 54437-52 or unlisted and benchmarked to one of those codes?
Thoughts...?
 

thomas7331

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I would use the unlisted code - there isn't a specified code for an exploration/diagnostic procedure, which is what you have here, so I don't think documentation or the final diagnosis will support using either of the listed codes in its place.
 
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Looking at this another way, I would suggest the following coding for your clinical scenario:
54437-52 for a reduced procedure to repair a corporal tear which was not found, therefore the reduced modifier-52. The procedure was performed for a suspected diagnosis of S39.848A, but the rupture was not found. Therefore, add to your diagnosis of S39.848A the ICD-10-CM diagnosis Z71.1, pathology not found.
 

thomas7331

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Looking at this another way, I would suggest the following coding for your clinical scenario:
54437-52 for a reduced procedure to repair a corporal tear which was not found, therefore the reduced modifier-52. The procedure was performed for a suspected diagnosis of S39.848A, but the rupture was not found. Therefore, add to your diagnosis of S39.848A the ICD-10-CM diagnosis Z71.1, pathology not found.
I think that the 54437-52 coding is valid for purposes of reporting the work performed, but it would not be possible to code the suspected diagnosis on a physician or outpatient hospital claim (a suspected diagnosis that was ruled out can only be coded on an inpatient hospital claim). Which is why I think lean toward the unlisted code instead - so that you're not reporting a CPT code for a procedure that doesn't have a supporting diagnosis.
 
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