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new coder needs help - penile exploration

  1. #1
    Default new coder needs help - penile exploration
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    Any suggestions for CPT. Any help is appreciated. Thanks.
    Doctor states dx as fractured penis, penile hematoma

    Procedure: penile exploration with removal of penile hematoma and repair of right corpora cavernosum.

    Op note reads:
    The penis was quite ecchymotic and one could palpate a hematoma and discontinuity on the right corpora cavernosum at approximately 1 inch below the right subcoronal sulcus. A circumferential incision was made around the subcarinal sulcus and shaft skin of the penis was carefully dissected downward, approximately halfway down the penile shaft, exposing an obvious hematoma of the right corpora cavernosum. An S-shaped incision was made in the tunica albuginea, relieving at least 3-4 ml of old blood clot within the corpora cavernosum. This area of the corpora cavernosum was then irrigated with hydrogen peroxide and saline to remove his old hematoma to prevent any future fibrosis or calcification. The tunica albuginea was carefully closed with 3-0 Vicryl with vertical mattress sutures to get good apposition of the tunica albuginea with good healing. The shaft skin was thens sutured to the subcarinal cuff with interrupted and running 3-0 chromic catgut for a nice cosmetic closure. Xeroform and roll gauze dressing was applied for hemostasis.

  2. Default
    54015 or 54440. I'd lean more toward 54015.

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