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Audrey Posted 7 Year(s) ago

Any suggestions would be great- how to code left inguinal exploration with evacuation of penile hematoma



SuperCoder Posted 7 Year(s) ago

Would 54015 (Incision and dranage of penis, deep) possibly be appropriate for the evacuation, Audrey? The exploration would be included in the code for the rest of the procedure. I'll do some research and see if I come up with a better code, too.


SuperCoder Posted 7 Year(s) ago

I thought more about this and conferred with a colleague and have a few additional thoughts. I still think 54015 might be appropriate, depending on how deep your urologist had to go. If he just incised the skin though, 10140 might be more appropriate. My colleague said she'd likely choose 10140 if no drain was left in place and 54015 if a drain was left in place. Or, if your physician went through “skin and deeper tissues” I would lean toward 54015.

Also, according to the CCI edits for 55110 (scrotal exploration), it appears that neither of these two codes, (54015 or 10140) is bundled with the scrotal exploration, so you may also be able to report 55110. If the hematoma were at the base of the penis (in the penoscrotal junction) I'd suggest not charging for both; however, if the hematoma is more distal on the penis, I would consider charging for both.

I hope that helps you.


Leesa A. Israel, CPC, CUC, CMBS
Executive Editor, The Coding Institute

Posted by Audrey, 7 Year(s). There are 3 posts. The latest reply is from SuperCoder.

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