David H. Ewalt, MD, FAAP
Urology Clinics of North Texas
North Texas Pediatric Urology Associates
Dallas, Texas
AAP 10/8/06

• Document explicitly in the operative note the exact procedure performed
• Use the most accurate ICD-9 codes for the diagnosis and most applicable CPT code(s) for the procedure performed
• Coding is NOT an exact science

• 54300 - Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra. RVU 10.39
•
54304 - Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce and/or skin flaps 12.47
• 54360 - Plastic operation on penis to correct angulation. 11.91

• Case # 1
• History:
• 6 month old male with distal (1 cm) hypospadias with moderate chordee and tethering of the scrotum to the ventral penis.
• Procedure performed:
• Tubulerized incised plate urethroplasty procedure performed with deepithelialized vascular pedicle from right Byars flap to cover the repair along with removal of excess prepuce. Plication of the dorsal corpora performed to correct chordee.
Simple scrotoplasty to correct penoscrotal fusion.

CPT Code Usage – Case # 1
•
54324 - One stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps (eg, flip-flap, prepucial flap). 16.29
• 54326 - One stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps and mobilization of urethra. 15.70
• 54328 - One stage distal hypospadias repair (with or without chordee or circumcision); with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/or island flap. 15.63
•
15740 - Flap; island pedicle. 10.23
•
14040 - Adjacent tissue transfer or rearrangement, genitalia; defect 10 sq cm or less. 7.86
• 55175 - Scrotoplasty; simple. 5.23
• 55180 - Scrotoplasty; complicated. 10.70
• 54300 - Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra. 10.39
• 54360 - Plastic operation on penis to correct angulation. 11.91
• 54161 - Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn. 3.27
• 54235 - Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine). 1.19

55175
54324
14040
54326
54328
54235
54300
15740
54360
55180
54161
0
52
59
10
12
12
11
10
16
19
20
25
30
32
30 40 50 60 70

Number of CPT codes assigned – Case # 1
2006 Pediatric Urology Coding Survey
35
30
25
20
15
10
5
0
1 2 3 4 5
Number of CPT Codes Assigned - Case #1
6

•
54324 One stage distal hypospadias repair
(with or without chordee or circumcision); with urethroplasty by local skin flaps (eg, flip-flap, prepucial flap). 16.29
•
15740 Flap; island pedicle. 10.23
•
55175 Scrotoplasty; simple. 5.23

•
Case # 2
• History:
• 6 month old male with buried or concealed penis.
• Procedure performed:
• Phalloplasty with rotation of dorsal preputial flaps to cover the ventral penis along with removal of excess prepuce.

CPT Code Usage – Case # 2
• 54300 - Plastic operation of penis for straightening of chordee
(eg, hypospadias), with or without mobilization of urethra. 10.39
•
54304 - Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce and/or skin flaps 12.47
•
54360 - Plastic operation on penis to correct angulation. 11.91
•
14040 - Adjacent tissue transfer or rearrangement, genitalia; defect 10 sq cm or less. 7.86
•
54161 - Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn. 3.27
• 55175 - Scrotoplasty; simple. 5.23
•
54180 - Scrotoplasty; complicated. 10.70
• 55899 - Unlisted procedure, male genital system ??

14040
55175
54300
54161
54360
54304
54180
55899
0
3
5
6
10
15
15 20 25
29
31
33
35
35
30 35 40

Number of CPT codes assigned – Case # 2
2006 Pediatric Urology Coding Survey
25
20
15
35
30
10
5
0
50
45
40
1 2 3 4
# of CPT Codes Assigned - Case #2
5

•
54300 Plastic operation on penis to correct angulation. 10.39
•
14040 Adjacent tissue transfer or rearrangement, genitalia; defect 10 sq cm or less. 7.86

•
Case # 3
• History:
• 6 month old male with chordee without hypospadias.
• Procedure performed:
• Phalloplasty with rotation of dorsal preputial flaps to cover the ventral penis along with removal of excess prepuce.
Corporal placation performed to correct chordee.

CPT Code Usage – Case # 3
• 54300 – Plastic operation of penis for straightening of chordee
(eg, hypospadias), with or without mobilization of urethra.
10.39
•
54304
– Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce and/or skin flaps. 12.47
•
54360
– Plastic operation on penis to correct angulation.
11.91
• 14040 – Adjacent tissue transfer or rearrangement, genitalia; defect 10 sq cm or less. 7.86
•
54161
– Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn. 3.27
• 54235 – Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine). 1.19

54300
54161
14040
54360
54304
54235
Other
0
7
10
11
20
26
25
25
29
30 40 50 60
60
70

40
30
20
10
0
60
50
Number of CPT codes assigned – Case # 3
2006 Pediatric Urology Coding Survey
1 2 3 4
# of CPT Codes Assigned - Case #3
5

•
54304 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra. 12.47
•
14040 Adjacent tissue transfer or rearrangement, genitalia; defect 10 sq cm or less. 7.86