David Ewalt, MD

	The AUA Coding and Reimbursement Committee, American Academy of Pediatric Urology, urology fellows of the American Academy of Pediatrics, and members of the Pediatric Urology Coordinating Council of the Society of Pediatric Urology recently published a consensus document on suggested coding guidance for pediatric hypospadias repair. 

	Coding for this procedure has concerned pediatric urologists for many years. As a result of numerous questions received on the AUA Coding Hotline and since no consensus could be identified on the appropriate reporting of hypospadias repair, the AUA Coding and Reimbursement Committee convened a workgroup of pediatric urologic experts from around the country to discuss coding guidelines for hypospadias reconstruction. Once the coding guidelines were defined, the AUA recommendations were vetted through members of the four organizations above to gain consensus on proper reporting of this procedure and all the components involved. The most common comment concerned the correction of penile curvature or penile chordee.

	Penile chordee has always been an integral component of all primary hypospadias repairs and therefore should not be unbundled as a separate procedure. However, many additional adjunct or secondary procedures have been developed and refined over the past 3 decades that do qualify for unbundling, as they require additional time and effort to complete. More importantly, the adoption of these techniques has improved the functional and cosmetic outcomes of these complex penile reconstructions with a lower complication and surgical revision rate.

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	Hypospadias is not a uniform disorder, which explains the plethora of CPT codes used to describe its surgical correction. Distal and mid-shaft hypospadias is the most common type of hypospadias (in which the urethral orifice opens at the mid or distal shaft of the penis) and is usually corrected in a single surgical procedure (one-stage repair). Proximal and perineal hypospadias is less common and is often associated with severe ventral penile curvature with or without abnormal scrotal development and may require surgical staging (two-stage repair) to correct.

	Primary procedures codes represent the baseline or primary hypospadias repair code for either a one-stage repair or the first or second stage of a planned two-stage repair. Secondary procedure codes represent additional or adjunct procedures performed in conjunction with the primary procedure. These may include a variety of more recently described tissue flaps, grafts, and scrotal procedures that have been developed and incorporated with the primary procedure. They are now routinely performed in hypospadias reconstruction to decrease surgical complications, decrease the need for revision surgery, and improve cosmetic outcomes.

	Coding guidelines for hypospadias repair

	The recommendations are guidelines with a degree of latitude given the variability of associated anomalies found in conjunction with hypospadias (penile chordee or angulation, penile torsion, peno-scrotal fusion, bifid scrotum, peno-scrotal transposition). After careful review and discussion, a guideline for coding five typical clinical scenarios was developed for 

 surgical repairs. These guidelines are for initial hypospadias repairs only and are not to be used for repair of hypospadias complications or revision surgery. Detailed documentation in the operative report must support the use of each primary and secondary code (additional codes 

 be used as the guideline is not intended to include all codes given the variety of techniques utilized for hypospadias surgery).

	Additionally, if possible, the medical rationale for the use of a secondary code to improve the outcome of the surgery is encouraged. Correction of penile chordee or penile curvature for 

 single-stage repairs has always been included with all primary codes since their inception regardless of the technique used to effect penile straightening.

	Ronald P. Kaufman, Jr., MD, chair of the Coding and Reimbursement Committee, shared: “Dr. Ewalt and his collaborators are to be congratulated for their hard work with regard to the guidelines that they have provided for the coding of pediatric hypospadias repair. Their structured and organized approach to the coding of pediatric hypospadias repair will provide for detailed and accurate coding in this often confusing area.”

	To see the coding guidelines in full, go to 

	*In addition to Dr. Ewalt, the members of the AUA Pediatric Hypospadias Workgroup include Howard M. Snyder, III, MD, Children’s Hospital of Philadelphia; Mark C. Adams, MD, Vanderbilt Hospital, Nashville, TN; Laurence S. Baskin, MD, University of California, San Francisco Benioff Children’s Hospital; Douglas A. Canning, MD, Children's Hospital of Philadelphia ; Earl Y. Cheng, MD, Lurie Children’s Hospital of Chicago; and Bradley P. Kropp, MD, University of Oklahoma Health Sciences Center, Oklahoma City.

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Articles

The AUA Coding and Reimbursement Committee, American Academy of Pediatric Urology, urology fellows of the American Academy of Pediatrics, and members of the Pediatric Urology Coordinating Council of the Society of Pediatric Urology recently published a consensus document on suggested coding guidance for pediatric hypospadias repair.

David Ewalt, MD

Articles

Hypospadias repair: AUA creates new consensus document on coding