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Urology- Meatotomy

Cherie Posted Fri 25th of July, 2014 08:24:42 AM

I have a question regarding coding. I will describe briefly the surgery.
An incision in the thickened supra pubic skin was made vertically in the 12 o'clock position. This allowed the penis to be exposed showing a normal phallus. The meatus was pinpoint in nature and thickening of the epithelium of the glans penis was also consistent with BXO or Lichen Sclerosus. The vertical incision was closed horizontally in a Heineke-Mikulicz fashion. This allowed adequate access to pull the penis forward. No attempt was made a a formal circumcision at this time, as it would likely require removal of supra pubic fat and perhaps placement of flaps. As noted previously, the meatus was pinpoint in nature. Using a hemostat, the meatus was opened in the 6 o'clock position. Following this, the epithelium of the glans penis was sewn to the urethral mucosa circumferentially using the 4-0 chromic.
I want to say this would be a CPT 53020. Please let me know your thoughts. Thank you.

SuperCoder Answered Mon 28th of July, 2014 07:53:18 AM

Yes, you are correct. Code 53020 would be appropriate in the above scenario if the patient is not an infant.

53020 represents 'Meatotomy, cutting of meatus (separate procedure); except infant'.

Thanks !!

SuperCoder Answered Mon 28th of July, 2014 07:56:12 AM

Code 53020’s descriptor indicates it is a separate procedure, meaning that you cannot report this code separately with a related procedure when performed in an anatomically related region through the same skin incision. If the provider performs the 53020 procedure with an unrelated procedure, you may need to append modifier 59 to 53020.

Thanks !!

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