Circumcision
[Phimosis / recurrent balanoposthitis / lichen sclerosus / patient preference]
Same
Circumcision, [sleeve resection / Gomco clamp / Mogen clamp / Plastibell device] technique
[***, MD/DO]
[Resident/Fellow/PA name]
[General / IV sedation with MAC / dorsal penile nerve block / ring block]
Patient presents with [phimosis causing urinary obstruction / recurrent balanoposthitis / lichen sclerosus (BXO) / patient preference]. Conservative management with [topical steroid / barrier cream] [failed / not desired / not appropriate given extent of disease]. Risks including bleeding, hematoma, wound infection, altered glans sensation, cosmetic outcome, injury to glans or urethra, skin bridge formation, and need for revision discussed. Consent obtained.
[Phimotic / redundant / normal] foreskin with [scarring consistent with lichen sclerosus / inflammation / normal appearance] of the prepuce. Glans [fully visible after retraction / partially visible / not visible]. Frenulum [normal / short / adherent].
The patient was positioned supine and prepped and draped in sterile fashion. [A dorsal penile nerve block was performed using [X] mL of 0.5% bupivacaine without epinephrine, infiltrated at the 10 and 2 o'clock positions at the penile base just below the symphysis pubis, advancing through Scarpa's fascia and Buck's fascia. A ring block with an additional [X] mL was placed circumferentially in the subcutaneous tissue at the penile base.]
The foreskin was retracted. [In phimotic cases, a short dorsal slit was made to allow full retraction.] The coronal sulcus was identified. The outer skin marking was made on the penile shaft at the projected level of the coronal sulcus (with the foreskin in the reduced position, approximately at the corona). The inner mucosal marking was made on the inner preputial surface approximately [0.5-1] cm proximal to the corona, preserving a collar of inner mucosal tissue.
Using a sleeve resection technique, the outer prepuce was incised circumferentially along the outer marking. The inner prepuce was incised circumferentially along the inner marking. The intervening sleeve of foreskin was excised. The frenular vessels at the ventral frenulum were specifically controlled with electrocautery [and suture-ligated with 3-0 Vicryl if a discrete vessel was encountered]; the frenular region is the most common site of post-operative bleeding and warrants particular attention. Additional hemostasis was achieved with bipolar electrocautery. The mucosal and skin edges were re-approximated with interrupted 4-0 Vicryl Rapide [/ 4-0 chromic / 4-0 plain gut] sutures placed at four quadrants, followed by additional sutures for a circumferential closure.
A compressive non-circumferential dressing was applied. Patient tolerated the procedure well.
None
[Foreskin sent to pathology / Foreskin discarded]
Minimal
None
Patient was taken to PACU in stable condition. Discharged same day. Post-op instructions given (keep dressing 24-48 hours, warm soaks starting day 3, no intercourse/masturbation for 4-6 weeks, follow up in 2 weeks).
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Phimosis / recurrent balanoposthitis / lichen sclerosus / patient preference]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Circumcision, sleeve resection technique
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General / dorsal penile nerve block (0.5% bupivacaine WITHOUT epinephrine)
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [phimosis / recurrent balanoposthitis / lichen sclerosus / patient preference]. Conservative management [failed / not appropriate]. Risks of bleeding, hematoma, infection, altered sensation, cosmetic outcome, and glans/urethral injury discussed. Informed consent obtained.
FINDINGS: [Phimotic / redundant] foreskin with [scarring / inflammation / normal appearance]. Glans [visible / partially visible / not visible]. Frenulum [normal / short].
DESCRIPTION OF PROCEDURE:
Patient supine, prepped in sterile fashion. [DPNB: *** mL 0.5% bupivacaine WITHOUT epinephrine at 10 and 2 o'clock, subpubic, advancing through Buck's fascia; ring block *** mL subcutaneous.] Foreskin retracted. [Dorsal slit for phimosis.] Outer skin marking at projected coronal sulcus level on shaft. Inner mucosal marking 0.5-1 cm proximal to corona. Sleeve resection: outer prepuce incised circumferentially; inner prepuce incised circumferentially; foreskin sleeve excised. Frenular vessels controlled with electrocautery [and suture ligation 3-0 Vicryl if needed]. Hemostasis bipolar electrocautery. Edges approximated interrupted 4-0 Vicryl Rapide at quadrants then circumferentially. Non-circumferential compressive dressing. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: [Foreskin to pathology / Discarded]
COMPLICATIONS: None
DRAINS: None
DISPOSITION: PACU, discharged same day. Follow up 2 weeks.
Signed: .ME, .MYDEGREE
.TODAYVariants
Neonatal clamp technique — Gomco/Mogen/Plastibell
Gomco clamp: bell placed over glans, clamp assembled, crushing of foreskin for 5 minutes, excision. Mogen clamp: faster, slightly higher glans injury risk, no bell required. Plastibell: ring device left in place; foreskin necrotizes and falls off at 5-10 days; preferred by some pediatricians. 0-day global means same-day nursery visits are separately billable; no post-op bundling.
Dorsal slit technique
For severe phimosis when circumcision is not feasible or not desired. Longitudinal dorsal incision releases the phimotic ring.
Preputioplasty (foreskin-sparing)
Y-V plasty or dorsal slit with transverse closure for mild phimosis. Foreskin is preserved. Document indication (desire to retain foreskin) and technique.
Lichen sclerosus (BXO)
Document extent of involvement — meatal involvement, corporal involvement, or urethral stricture requires additional procedures. Always send foreskin to pathology (ICD-10 L90.0). Margin status should be assessed by pathology. If meatal stenosis is present at time of surgery, meatotomy/meatoplasty may be performed concurrently; document separately.
Post-circumcision adhesion lysis
Office lysis of minor adhesions without anesthesia is bundled into established-patient E/M. Document the need for OR-level intervention (extent of adhesions, failure of office management, need for anesthesia).
Charting Tips
- Document indication specifically — affects insurance coverage and ICD-10. Phimosis (N47.1), paraphimosis (N47.2), recurrent balanoposthitis (N47.6), lichen sclerosus (L90.0). Cosmetic/elective adult circumcision is not covered by most payers; prior authorization required.
- Document technique — sleeve resection, Gomco clamp, Mogen clamp, or Plastibell.
- Document nerve block agent and confirm no epinephrine. Epinephrine is absolutely contraindicated in penile blocks. Document: 'dorsal penile nerve block performed with 0.5% bupivacaine without epinephrine.'
- Document frenular management. If frenulum is short or tethering, frenuloplasty/frenulotomy may be needed.
- Send foreskin to pathology for: adults over 50, lichen sclerosus/BXO, abnormal gross appearance, chronic recurrent balanitis, or any concern for malignancy. Squamous cell carcinoma of the penis, erythroplasia of Queyrat, and Bowen disease can all be found in otherwise-routine circumcision specimens.
Documentation & Reimbursement Considerations
- Report Circumcision as the primary service when it is the definitive operation performed.
- The distinguishing feature from neonatal codes is age 28 days or older.
- Neonatal circumcision splits by technique, not by setting. The split is technique-based, not setting-based.
- Global period differs by code.
- Frenular takedown during circumcision is inherent to the procedure. Do not separately report the related service when performed at the same session as circumcision.
- Adult circumcision: many payers consider it cosmetic without documented medical indication. Obtain prior authorization for elective cases and document the specific indication (phimosis N47.1, paraphimosis N47.2, recurrent balanoposthitis N47.6, lichen sclerosus L90.0, or recurrent balanitis N48.1). Cosmetic motivation alone is non-covered.