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Coding Advice: Phalloplasty for penile scarring and adhesions

Leah Posted Mon 22nd of September, 2014 11:30:29 AM

Hello,
Patient presented for phalloplasty. The patient is morbidly obese and has had multiple surgeries including circumcision to correct his adhesions but because of his habitus, the skin continues to grow over, and he now has very little penile shaft skin. The patient has tethering of the penis due to a band of scar tissue at the base. Procedure is as follows:
"The band of scar tissue was identified and incised. The skin circumferentially was undermined, generating skin flaps most prominently at the suprapubic region. These flaps were then brought together and the incision was closed in a Heineke-Mikulics type fashion. the deep dermis and subcutaneous tissues were approximated with interrupted 3-0 vicryl suture. The skin was closed with interrupted 4-0 monocryl suture"
Will you please give me guidance as to how this should be coded? I usually look to the 1142x series in the CPT for scar revision, but I am stuck regarding the skin flaps.
Thank you
Leah
CPC, CUC

SuperCoder Answered Wed 24th of September, 2014 09:54:49 AM

Thanks for your question.

This should be coded with the CPT code 54304. As this code represents plastic operation on penis for correction of chordee (tethering of penis due to band of scar tissue at the base) along with Plastic operation (generation of skin flaps most prominently at the suprapubic region).

Hope it answers your query.

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