1. 2006 Panel on CodingDiagnostic 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 • 752.61 Hypospadias • Chordee • 752.63 Congenital chordee • Penoscrotal tethering • 752.81 Scrotal transposition  • Preputial redundancy/asymmetry • 605 Redundant prepuce and phimosis

6. Case #1: • Diagnosis and Procedural “Code Pairing” • Hypospadias • 752.61 Hypospadias • 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

7. 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

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 • 752.65 Hidden penis • Penoscrotal web • 752.81 Scrotal transposition • 752.63 Congenital chordee • Preputial redundancy/asymmetry • 605 Redundant prepuce and phimosis

10. Case #2: • Diagnosis and Procedural “code pairing” • Buried penis • 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

11. 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

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

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

14. 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

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 • (752.51) Undescended testis

17. 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

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 • 550.90 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 ( 778.6 ) • 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!