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Scenario Week of March 13, 2014:
View Current Scenario

Assign the correct codes for the following scenario using ICD-9-CM and CPT procedure codes:

Preoperative Diagnoses

  1. Impotence, longstanding
  2. Diabetes mellitus, longstanding
  3. Failure of conservative approach
  4. History of coronary artery disease contributing to hypertension and arteriosclerosis
  5. History of pulmonary embolism in the past. Clearance has been achieved from Cardiology

Postoperative Diagnoses

  1. Impotence, longstanding
  2. Diabetes mellitus, longstanding
  3. Failure of conservative approach
  4. History of coronary artery disease contributing to hypertension and arteriosclerosis
  5. History of pulmonary embolism in the past. Clearance has been achieved from Cardiology
  6. Very thickened and scarred corpora cavernosa

The patient had to take Lovenox in preparation for surgery because he takes Coumadin routinely. PT and PTT preoperatively were normal.

Procedure: Insertion of 3-piece penile prosthesis
Complications: None
Condition: Good
Anesthesia: General
Estimated blood loss: 50 cc
Specimen delivered: None
Counts: Correct x3
IV fluids: See anesthesia record
Urine output: See Foley bag

Antibiotic utilized: Patient received Levaquin and Vancomycin in preparation for surgery because of the diabetes, high-risk patient for infection

Indications: The patient has had a longstanding problem with impotence for several years. He has a history of arthritis, coronary artery disease, diabetes mellitus, insulin dependence, and has tried multiple modalities of treatment in the past, including medical therapy and injection therapy from device. Patient has expressed frustration with this condition for several years; testosterone and libido are normal. Patient and his wife have attended a number of seminars on impotence and are aware of the other options available to them which include penile prosthesis.

The patient and his wife have done extensive research on the Coloplast penile prosthesis using Titan covering and are aware of and understand the success rate as documented in the medical literature, as well as the associated risk of complications from penile prosthesis that include:

  1. Bleeding
  2. Infection
  3. Scarring
  4. Perforation of corpora
  5. Dysfunction
  6. Need for removal or revision of prosthesis
  7. Deep venous thrombosis
  8. Embolism

The patient has been taking Lovenox for the last 5-6 days in preparation for surgery and his preoperative PT and PTT are normal.

Lengthy discussions have occurred with the patient on many occasions prior to deciding on the penile prosthesis insertion procedure. The patient has received educational brochures in addition to a web site where the patient has done extensive research and has also reviewed my slide presentation.

Procedure in detail: The patient was taken to the operating room post anesthesia, then in the supine position, ECOs were applied. The area was prepped and draped in the usual sterile fashion for a prosthetic surgery. The penis was isolated in the surgical site, and a Foley catheter was inserted with ease. Clear urine was drained in the bag. A suprapubic incision was made for an infrapubic approach, about 4 to 5 cm in length, deepened through skin, subcutaneous tissue, and deep fascia. The base of the penis was exposed as well as the corporal tissue after incision of the fascial covering of the corpora on each side. Stay sutures were applied to both sides of the corpora for purposes of delineation of incision using 2-0 Vicryl.

Then, I was able to do the corporotomy individually; the corpora were opened adequately, which were very thick, fibrosed, and calcified related to the longstanding fibrosis. Corporotomy was defined on each side. Antibiotic irrigation was continuously used in the procedure. The corpora were dilated proximally and distally to a total of 13-French.

Length of the prostatic urethra was judged with the Furlow tool, and the estimated length was about 14 cm in this uncircumcised penis.

I was then able to isolate the Coloplast prosthesis, a Titan prosthesis about 40 cm in length with an 11 mm cylinder and extenders were applied for over 1 cm. Using proper precautions, as recommended by the Coloplast company, the cylinders were primed with an antibiotic coating using the antibiotic Rifampin; the cylinders were flattened and the reservoir was filled appropriately without any air pockets.

The tubings were clamped. Then, the proximal end of the scope was inserted using the Furlow tool toward the glans with ease and a proximal extension was inserted through a corporotomy to the ischial attachment. Good length of corpora was noted without any tension on the glans.

Vigorous antibiotic irrigation was performed routinely. Then on the right side, the subcutaneous tissue covering the external ring was exposed and through blunt dissection, the retropubic space was probed and identified. Following this, on the side table, I prepared the reservoir. Again, using proper precautions with the antibiotic coating, an airtight system was created. The reservoir was then placed and a plane created underneath the external ring in the retropubic space with the assistance of a blunt instrument.

After displacement, the tubings, which had been clamped appropriately with rubber shots and were redundant, were excised with rubber shots proximally on both sides. Airtight approach was conducted all through the procedure. To create a space for the pump on the right side, subcutaneous dissection was done with sponge forceps and on the right side of the testicle; I was able to create space easily. The pump was placed anteriorly for application purposes with ease. After proper placement, antibiotic irrigation was performed repeatedly. Following this, the corporotomy was closed with 3-0 Vicryl intermittently without damage to the elements of the prosthesis. Good hemostasis was evident at the end of procedure. Counts were correct x3 for sponges, laps, and instruments. Deep fascia was approximated with 3-0 Vicryl as was the superficial fascia. Skin was approximated with staples. A 4x4 dressing was applied tightly. The patient was taken to recovery in good condition. I anticipate some swelling and ecchymosis in this patient because he does take Lovenox. Postoperative care was explained to the patient on multiple occasions prior to and after surgery as well as proper precautions for antibiotic usage. The patient will stay overnight for administration of vancomycin and pain control as well as Levaquin tomorrow. The patient's catheter will be removed tomorrow morning.

Select the correct CPT and ICD-9-CM codes for this office visit.

Answers and Rationale

CPT Code
54405 Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir

In the index of CPT 2014 Professional Edition, under the main term “penile prosthesis,” subterm “insertion, inflatable,” the code range provided is 54401-54405. The code description for 54405 describes a “multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir.” The physician documented the procedure as “Insertion of 3-piece penile prosthesis” and all of the components listed in the code descriptor are present in the operative report.

ICD-9-CM Diagnosis Codes
607.84 Impotence of organic origin
250.00 Diabetes mellitus, without mention of complication, insulin dependent

In the alphabetic index under the main term “Impotence,” the coder can select from “sexual” or “organic origin NEC,” both of which refer to code 607.84, or “psychogenic” which refers to code 302.72, a code from the Mental, Behavioral and Neurodevelopmental Disorders chapter. Diabetes mellitus is commonly associated with contributing to impotence because it can cause damage to the blood vessels and nerves that control an erection even when the patient has a normal libido and normal testosterone levels. Note the physician made reference to this in the operative report. The physician has documented the patient as having diabetes mellitus. Furthermore, there is no reference to the patient having an associated mental, behavioral, or neurodevelopmental disorder contributing to the impotence; therefore, correct code assignment is 607.84.

The surgeon documented “diabetes mellitus, longstanding,” and later in the body of the operative report under “Indications” the physician described the patient as having “diabetes mellitus, insulin dependent.” However, the physician made no mention of how long the patient has been taking insulin. Per ICD-9-CM coding guidelines, “All type I diabetics must use insulin to replace what their bodies do not produce. However, the use of insulin does not mean that a patient is a type I diabetic. Some patients with type II diabetes mellitus are unable to control their blood sugar through diet and oral medication alone and do require insulin. If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, the appropriate fifth-digit for type II must be used. For type II patients who routinely use insulin, code V58.67, Long-term (current) use of insulin, should also be assigned to indicate that the patient uses insulin. Code V58.67 should not be assigned if insulin is given temporarily to bring a type II patient’s blood sugar under control during an encounter.” Because the physician did not specify long term use, it would be inappropriate to include code V58.67.

According to the International Classification of Diseases, 9th Revision, Clinical Modification, instructional guidance under subcategory 250.0 Diabetes Mellitus, without mention of complication, indicates a 5th digit subclassification is required for use with codes from category 250. Since the physician has not indicated any specific complications, 250.0 would be the correct diagnosis code, and the 5th digit subclassification would be “0” because the provider did not specify whether the DM was uncontrolled nor was any specific manifestation documented. Furthermore, the 5th digit subclassification of “0” states that it is appropriate for use, “even if the patient requires insulin.” This diagnosis code is listed first as listed on the operative report. Note that this code is listed in the alphabetic index under “Diabetes, diabetic” as the main term with code 250.0 shown and guidance to assign the 5th digit subclassification. Always confirm code selection in the tabular section.

It is important to note that when coding for the inpatient setting, the principal diagnosis is the diagnosis that describes the reason for the patient encounter or procedure.

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