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  • Posted by 4836, 3 years ago. There are 2 posts. The latest reply is from SuperCoder.
  1. Is there another code beside '54120'[Amputation of penis: partial] for the Urethra reconstruction? I have 1 code in mind '53410'[1-stage reconstruction of male anterior urethra] but not sure if the urethra reconstruction is included in '54120'.

    PROCEDURE: Partial tenectomy

    INDICATIONS: This is a 76-year-old gentleman who presents with a history of a penile mass. He states the problem started approximately 8 to 9 months ago when he noticed a lesion on the penis. Shortly after that, he developed bilateral groin masses and these appeared to be either cancers or inflammatory. According to the patient, his primary doctor or other health care provider performed an incision and attempted drainage of the right
    inguinal groin nodes. Since that time that area has expanded in size and is extremely purulent, foul-smelling. On CT scan, patient had a large heterogeneous solid mass involving the penis and likely involvement of inguinal nodes versus inflammatory nodes. There was also at least one node intra-abdominally. The patient was offered partial tenectomy for purposes of histologic diagnosis as well as local control. Risks, benefits, and alternatives including that of long term erectile dysfunction were carefully discussed. Patient understands. He is seen at this time for further management.

    OPERATIVE SUMMARY: Patient was prepped and draped in usual sterile fashion in
    the supine position. Careful time-out procedure was performed identifying
    patient and procedure correctly. A glove was used to isolate the penile tumor
    from the rest of the surgical field. When this was outlined using pen,
    partial tenectomy was completed by amputating the penis. Care was taken to
    allow for some dorsal skin to be extra over the top. At this point, a
    tourniquet using a Penrose drain was used to control blood loss. The corporal
    bodies were individually oversewn with 3-0 Monocryl. The urethra was
    spatulated anteriorly and was brought through a buttonhole, which was created
    on the dorsal foot of skin and secured with 3-0 Monocryl. The urethral meatus
    was then splayed open. A stoma type arrangement was created at the opening in
    the penile skin. The skin edges of the penis were then closed with
    interrupted 4-0 chromics. A 16-French Foley catheter was then inserted into
    the bladder and clear urine was obtained. Next, attention was turned to the
    right groin, which was then irrigated using pulse lavage and GU antibiotic.
    Because of the uncertainty of the depth of this lesion and its close proximity
    to the vessels, no significant debridement of the area was attempted at this
    point in time. The area was then packed with sterile gauze. Antibiotic
    ointment was applied to the penile incision. The catheter was connected to
    gravity drainage. All sponge, needle, instrument counts were correct x3
    following the case. Patient was sent to recovery in stable condition. The
    patient will be observed for 23 hours in the hospital prior to discharge.

  2. Hi Yolanda.

    You're correct to report the partial amputation (partial penectomy) with 54120. That is the only code you should report for this procedure. When the urologist does this procedure, he has to make an opening for the urethra, and that's included in the main procedure code. Therefore, you cannot report a separate code, such as 53410, for the work to create/reconstruct the urethra.

    Best,
    Leesa

    Leesa A. Israel, CPC, CUC, CMBS
    Executive Editor, The Coding Institute
    leesai@codinginstitute.com

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