2006 Panel on Coding Diagnostic Coding and Documentation David R. Vandersteen, MD Children’s Hospitals of Minnesota Mayo Graduate School of Medicine

Coding and Documentation Tips “Code Pairing” List appropriate diagnoses to match the procedures performed Example: If doing a circumcision, use the redundant prepuce ICD-9 diagnostic code. If Code Pairing not possible Document what you do Document why you did it! Be specific!

General coding tips Describe details of the procedure to justify the “unpaired” codes Example: 14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less Dictate “Dorsal preputial rotational flaps were mobilized on a vascular pedicle, rotated ventrally, and used to resurface a 1 sq cm surface of deficient ventral penile skin.”

Case #1: 6 month old male with distal (1 cm) hypospadias with moderate chordee and tethering of the scrotum to the ventral penis.

Case #1: Diagnoses and ICD-9 codes Hypospadias Chordee 752.63 Congenital chordee Penoscrotal tethering  752.81 Scrotal transposition  Preputial redundancy/asymmetry 605 Redundant prepuce and phimosis

Case #1: Diagnosis and Procedural “Code Pairing” Hypospadias Chordee 54324 One stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps (eg, flip-flap, prepucial flap) Chordee 752.63 Congenital chordee 54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra

Case #1: Diagnosis and Procedural code “pairing” Penoscrotal tethering  752.81 Scrotal transposition  55175 Scrotoplasty; simple Excessive/asymmetric prepuce 605 Redundant prepuce and phimosis 54161 Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn

Case #2: 6 month old male with buried or concealed penis along with penoscrotal web.

Case #2: Diagnoses and ICD-9 codes Buried penis Penoscrotal web  752.65 Hidden penis Penoscrotal web  752.81 Scrotal transposition 752.63 Congenital chordee Preputial redundancy/asymmetry 605 Redundant prepuce and phimosis

Case #2: Diagnosis and Procedural “code pairing” Buried penis Chordee  752.65 Hidden penis ???? CPT code Chordee 752.63 Congenital chordee 54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra

Case #2: Diagnosis and Procedural code “pairing” Penoscrotal tethering  752.81 Scrotal transposition  55175 Scrotoplasty; simple Excessive/asymmetric prepuce 605 Redundant prepuce and phimosis 54161 Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn

Case #3: 6 month old male with chordee without hypospadias.

Case #3: Diagnoses and ICD-9 codes Chordee 752.63 Congenital chordee Preputial redundancy/asymmetry 605 Redundant prepuce and phimosis

Case #3: Diagnosis and Procedural “code pairing” Chordee 752.63 Congenital chordee 54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra Excessive/asymmetric prepuce 605 Redundant prepuce and phimosis 54161 Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn

Case #4: 1 year old with high testis at level of internal ring. Intra-op findings of large patent processus vaginalis/ hernia

Case #4: Diagnoses and ICD-9 codes Undescended testis

Case #4: Diagnoses and ICD-9 codes Inguinal hernia (550.9) Inguinal hernia, without mention of obstruction or gangrene  550.90 unilateral or unspecified (not specified as recurrent)  550.91 unilateral or unspecified, recurrent Congenital hydrocele (778.6) Congenital hydrocele Congenital hydrocele of tunica vaginalis

Case #5: 6 year old boy presents with a reducible communicating hydrocele.

Case #5: Diagnoses and ICD-9 codes Inguinal hernia? (550.9) Inguinal hernia, without mention of obstruction or gangrene  550.90 unilateral or unspecified (not specified as recurrent)

Case #5: Diagnoses and ICD-9 codes Hydrocele (778.6) Congenital hydrocele Congenital hydrocele of tunica vaginalis (603) Hydrocele Includes hydrocele of spermatic cord, testis, or tunica vaginalis Excludes congenital hydrocele ( 778.6 ) 603.8 Other specified types of hydrocele 603.9 Hydrocele, unspecified

General coding tips Utilize auacodingtoday.com! Free to all AUA members Easily access and search of both CPT and ICD-9 codes Bundling info/ cross check Updated Edits Access Medicare RVUs and Medicare fees for procedural codes Match ICD-9 codes to CPT codes i.e. Match diagnosis with procedure Document!