2006 Panel on Coding Diagnostic Coding and Documentation

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2006 Panel on CodingDiagnostic Coding and
Documentation

• David R. Vandersteen, MD
• Childrens Hospitals of Minnesota
• Mayo Graduate School of Medicine

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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!

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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.

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Case 1

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

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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

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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

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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
  

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Case 2

• 6 month old male with buried or concealed penis
  along with penoscrotal web.

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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

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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

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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
  

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Case 3

• 6 month old male with chordee without hypospadias.

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Case 3

• Diagnoses and ICD-9 codes
• Chordee
• 752.63 Congenital chordee
• Preputial redundancy/asymmetry
• 605 Redundant prepuce and phimosis

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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
  

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Case 4

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

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Case 4

• Diagnoses and ICD-9 codes
• Undescended testis
• (752.51) Undescended testis

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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

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Case 5

• 6 year old boy presents with a reducible
  communicating hydrocele.

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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)
  

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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

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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!