Thursday, August 25, 2011

Infant and Adult Circumcision Coding: Understanding the procedures and how to code them.

Infant and Adult Circumcision Coding: Understanding the procedures and how to code them.

When most of us hear the word circumcision, we immediately think about the procedure as performed on infants. Those of us that work in the urology field, have realized that circumcisions are performed on all ages, for many different reasons. Most often, circumcision is performed for religious, or cosmetic reasons. However, there are instances when it is medically necessary to have a circumcision performed. Most circumcision revision cases are required to repair side effects of disease, or surgical complications from previous surgery or trauma to the penis.

CPT-4 denotes the circumcision codes as those between 54150 and 54163; ICD-9 denotes the circumcision as code 64.0, code 64.49 as a repair of the penis, and V64.93 as a division of penile adhesions. As we transition to ICD-10PCS, I have cross coded the ICD-9 procedure codes in the table below. As you begin working more with I-10 you will become more familiar with the procedure codes/codesets. The GEMS mapping tables can be utilized, but many coders have found them to be inaccurate.
64.0 OVT|T|X|Z|Z
64.49 Multiple code choices
64.93 OVN|T|X|Z|Z

Circumcision Background:

Routine circumcision at birth for non-religious reasons is a common custom in the US and Canada. A parents’ wishes are varied as to whether or not to circumcise at birth. Circumcisions are frequently performed 24 hrs to 10 days after birth. Religious reasons for circumcision are very personal and for those cases it can be a ‘mandatory’ procedure regarding one’s faith. Religious reasons may dictate the timeframe, and it may vary as to when the procedure is performed, and by whom.

Medical necessity can also be a driving force for a newborn circumcision. However, medical necessity is a more common reason in adult or non-newborn circumcision(s), than cosmetic or routine circumcision. Adult circumcision can be performed strictly for cosmetic reasons, if the patient is unhappy with their current anatomical status. The most common medically necessary circumcision diagnosis is for a tight frenulum, balanitis, or a phimosis. If left untreated, penile cancer has been noted in men with long-standing untreated balanitis or phimosis. I

In cases of premature newborns, a circumcision procedure may be delayed until the patient is able to undergo the procedure by achieving a reasonable body weight and is no longer considered ‘at risk’ due to prematurity.


Basic Circumcision Procedure Code Details

The circumcision for an infant is a relatively simple procedure, and is denoted by the use of CPT code 54150/ICD-9 procedure code 64.0. A device such as a gomco clamp, or plastibell is used to remove the redundant skin and foreskin in a relatively quick excision type procedure. The clamp also stops the bleeding and bonds the edges of the skin together. Normally no sutures are needed. This type of procedure is commonly performed on the newborn by a pediatrician, a general or family practice physician, and sometimes even the OB physician. The parent of the newborn may also choose to have a urologist or even a member of the clergy to perform a circumcision.

CPT code 54160 denotes ‘surgical excision other than’ clamp, device or dorsal slit for infants 28 days or less, CPT code 54161 is for usage on patients above the age of 28 days. This code is more commonly used by urologists. Most urology practitioners prefer a surgical procedure, over usage of a device or clamp. The surgical excision procedure denoted by codes 54160/54161 provides a more precise excision of the excess skin, and oftentimes a better cosmetic outcome. If you are coding from the ICD-9 procedures, it does not differentiate between a surgical excision or one that uses a clamp or device.

Another key piece to the coding of a straightforward circumcision is the diagnosis. If the reason for the circumcision is a routine, cosmetic, religious or ritual circumcision the code V50.2 should be appended. However, if the circumcision is performed for a medically necessary reason, do not use V50.2. Use a diagnostic code to append with the claim such as balanitis, phimosis, or a penile anomaly.


Post circumcision revisions and repairs.

As with any surgical procedure, sometimes the outcome is not perfect. Circumcision surgery is no different. CPT-4 guides the coder to use code 54162 and ICD-9 directs the coder to use 64.93 for the lysis or excision of post-circumcision adhesions. It is interesting that ICD-9 describes the procedure as a ‘division of penile adhesions’, whereas CPT4 describes the procedure as ‘lysis or excision’ of post-circumcision adhesions. Another term you may hear or see in the operative report refers to a post-circumcision skin bridge. This is also a complication or late effect from the original circumcision procedure.

If the physician is repairing or revising and incomplete circumcision, CPT-4 directs us to use code 54163. It is important to note, that ICD-9 procedure codes do not have a separate code for this procedure. You will still need to use code 64.0. Careful review of the code verbiage and procedure documentation should be done by the coder. If unclear, be sure to query the physician for clarification.

One issue that has come up repeatedly is the coding and billing of the penile dorsal nerve block as anesthesia during circumcision. CPT allows for this procedure with code 64450, and appended with modfier -47 to indicate anesthesia by the physician performing the procedure. However, insurance payers and carriers may consider this a bundled procedure with a circumcision. As a coder, you will need to check the CCI bundling edits, and/or the 3rd party insurance carrier coding edits to see if they allow for payment of this anesthesia procedure in coordination with the circumcision. If the payer considers this anesthesia injection ‘bundled’, then it should not be billed. If you are unable to ascertain if payment by an insurance carrier is allowed, have the guarantor or patient sign an advance notice of non-coverage and collect for payment up front. Many 3rd party payers will not pay for a circumcision if it is for routine, ritual, religious or cosmetic reasons. Therefore, collecting payment for the procedure(s) and supplies up front is ideal.

The Operative Reports
In the case studies below, you can review these operative reports to fully understand the differences between the circumcision procedures, and the CPT and ICD9/ICD-10 procedure and diagnosis reporting codes.

Operative Case #1 Circumcision – Neonatal Procedure::
The procedure, risks and benefits were explained to the patient's mom, and a consent form was signed. She is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future. The 2 day old infant was placed on the papoose board.

Procedure Detail: The external genitalia prepped with Betadine. A penile block was performed with a 30-gauge needle and 1.5 mL of Nesacaine without epinephrine. Next, the foreskin was clamped at the 12 o'clock position back to the appropriate proximal extent of the circumcision on the dorsum of the penis. The incision was made. The appropriate size bell was obtained and placed over the glans penis. The Gomco clamp was then configured, and the foreskin was pulled through the opening of the Gomco. The bell was then placed and tightened down. Prior to do this, the penis was viewed circumferentially, and there was no excess of skin gathered, particularly in the area of the ventrum. A blade was used to incise circumferentially around the bell. The bell was removed. There was no significant bleeding, and a good cosmetic result was evident with the appropriate amount of skin removed. Vaseline gauze was then placed.

CPT Procedure: 54150 ICD-9 Procedure: 64.0 ICD-10 Procedure: OVT|T|X|Z|Z
ICD-9 Diagnosis: V50.2 ICD-10 Diagnosis: Z41.2


Operative Case #2 Post Circumcision Lysis of penile Adhesions

CC Office Visit/procedure Surgical followup of circumcision – lysis of adhesions.

HPI: The patient had his circumcision performed on 09/16/20XX at 4 months of age due to an extensive phimosis. The original circumcision was successful other than a little bit of bleeding upon awakening in recovery room. The post-op bleeding required placement of some additional sutures, but after that, his recovery has been complete.

Exam/Procedure: Today, we are 30 days post operative and patient looks healthy and happy. I examined his circumcision site. The monocryl sutures are still in place. The healing is excellent, and there is only a mild amount of residual postoperative swelling. There was one area where he had some recurrent adhesions at the coronal sulcus, and I gently lysed this today with a mini scalpel after application of topical anesthetic. Antibiotic ointment was then applied.

IMPRESSION: Satisfactory lysis of adhesions post circumcision for severe phimosis

CPT Procedure: 54162 ICD-9 Procedure: 64.93 ICD-10 Procedure: OVN|T|X|Z|Z
ICD-9 Diagnosis: 605 ICD-10 Diagnosis: N47.5

Operative Case #3 Adult Male Circumcision
PREOPERATIVE DIAGNOSIS: Bacterial Balanoposthitis , phimosis.and Penile Edema
PROCEDURE PERFORMED: Circumcision.
ANESTHESIA GIVEN: 30 cc of 0.25% Marcaine (plain) as a field block at the base and with a portion distributed at the frenulum; monitored anesthesia care and then general anesthesia with LMA.
FINDINGS: The patient was found to have massive edema of the foreskin without any evidence of purulence. No inflammatory changes were noted involving the glans penis.
DESCRIPTION OF THE PROCEDURE: After satisfactory placement in a supine position, the patient was induced with deep sedation. The MAC was provided by Dr. Abc, and was maintained throughout the procedure. I injected 30 cc of 0.25% Marcaine plain at the base of the penis and at the area of the frenulum. The area was prepared with thick jelly Betadine for good penetration and to keep the pubic hair away from the operative area. Dorsally, a straight clamp was passed across the edematous foreskin beginning at the level of the phimosis and the tissue was crushed. Along this relatively avascular line, the fine Metzenbaum scissors were used to divide the tissue to within about one centimeter of the glans. Similar incisions were made at three o'clock and nine o'clock and this produced wings of redundant markedly edematous penile skin. We were surprised to find no evidence of purulence and no inflammation of the glans penis nor the mucosa. A number of small bleeding points were noted around the shaft. These were clamped with fine hemostats and electrofulgurated. Fine chromic sutures were placed to provide complete hemostasis. The cut edge of the mucosa and the skin was then reapproximated with interrupted vertical mattress and horizontal mattress sutures of 2-0 chromic. Resolution of the bleeding and the swelling responded well to gentle pressure. Application of an antibiotic ointment, Xeroform gauze, and a circumferential gentle pressure dressing were provided. The patient was taken to the recovery area in satisfactory condition.
CPT Procedure: 54161 ICD-9 Procedure: 64.0 ICD-10 Procedure: OVT|T|X|Z|Z

ICD-9 Diagnosis: 607.83
ICD-9 Diagnosis: 607.1
ICD-9 Diagnosis: 605

ICD-10 Diagnosis: N48.89
ICD-10 Diagnosis: N47.6
ICD-10 Diagnosis: B96.89
ICD-10 Diagnosis: N47.1

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