1. 2006 Panel on Coding Diagnostic Coding and Documentation
David R. Vandersteen, MD
Children’s Hospitals of Minnesota
Mayo Graduate School of Medicine

2. 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!

3. 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.”

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

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

6. 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
Congenital chordee
54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra

7. Case #1: Diagnosis and Procedural code “pairing” Penoscrotal tethering
  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

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

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

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

11. Case #2: Diagnosis and Procedural code “pairing” Penoscrotal tethering
  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

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

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

14. Case #3: Diagnosis and Procedural “code pairing” Chordee
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

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

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

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

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

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

20. 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 ( )
603.8 Other specified types of hydrocele
603.9 Hydrocele, unspecified

21. 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!