Please help. The op note says phalloplasty. The patient is severely obese with a buried penis.
Op note reads
Using sharp and blunt dissection, further dissection (from prev dorsal slit) was carried down on the dorsal shaft of the penis. It was extremely difficult idenifying the glans penis as well as the penile shaft; however, with extreme meticulous dissection and a prolonged time element, the glans penis was identified, and mobilization was carried out around the dorsal aspect of the penis. Further cutdown was performed. There was extensive amounts of adhesions around the urethral meatus as well. Dissection was then carried laterally, both right and left side, using sharp and blunt dissection. Dissection was then carried toward the meatus. A large quantity of fibrotic tissue was adherent to the meatus; this was taken down with sharp dissection. Further dissection was carried ventrally, allowing exposure of the glans penis ventrally as well, at least for the glans penis to be exposed. Due to fibrosis no further dissection was carried more proximally on the ventral shaft. The dorsal incision was closed with 3-0 chromic suture, suturing more proximal to the more distal skin. Dissection sutures were also carried laterally, and a few sutures were placed ventrally as well. Again, due to extensive fibrosis, extensive time for phalloplasty mobilization of the penis was performed.
He also performed a cysto with dilation of urethra prior.
3M leads me to unlisted procedure.
I have codes, 15839, 54001, 52281, 55899
Please tell me if i am way off here. There is no way other than modifier to capture the complexity is there?
Thank you in Advance!
Hollie
Outpatient facility coder
Op note reads
Using sharp and blunt dissection, further dissection (from prev dorsal slit) was carried down on the dorsal shaft of the penis. It was extremely difficult idenifying the glans penis as well as the penile shaft; however, with extreme meticulous dissection and a prolonged time element, the glans penis was identified, and mobilization was carried out around the dorsal aspect of the penis. Further cutdown was performed. There was extensive amounts of adhesions around the urethral meatus as well. Dissection was then carried laterally, both right and left side, using sharp and blunt dissection. Dissection was then carried toward the meatus. A large quantity of fibrotic tissue was adherent to the meatus; this was taken down with sharp dissection. Further dissection was carried ventrally, allowing exposure of the glans penis ventrally as well, at least for the glans penis to be exposed. Due to fibrosis no further dissection was carried more proximally on the ventral shaft. The dorsal incision was closed with 3-0 chromic suture, suturing more proximal to the more distal skin. Dissection sutures were also carried laterally, and a few sutures were placed ventrally as well. Again, due to extensive fibrosis, extensive time for phalloplasty mobilization of the penis was performed.
He also performed a cysto with dilation of urethra prior.
3M leads me to unlisted procedure.
I have codes, 15839, 54001, 52281, 55899
Please tell me if i am way off here. There is no way other than modifier to capture the complexity is there?
Thank you in Advance!
Hollie
Outpatient facility coder