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Circumcision and Preventative visit

Chief complaint: weight check & circumcision
HPI formula feeding, gaining weight, appropriate responses..
Full ROS; negative as per HPI
Exam; comprehensive
Procedure note for the circumcision.
Assessment plan;
patient gaining weight appropriately
continue vitamin d exposure with sunlight
post operative care for circumcision.
Mention of next appointments

Would it be supported to bill for a ‘weight check’ Z00.111 99391 with the circumcision in the absence of a problem per se? Are weight checks in and of themselves necessary for babies? If a full history and exam are done at a circumcision is that enough for a wellness check if the chief complaint states "weight check and circumcision" ?

Thanks!

Medical Billing and Coding Forum

Circumcision

Dictation goes like this:

I performed a local penile block by injecting a combination of 2% lidocaine without epinephrine and 0.5% Marcaine, 5 mL at the 10 o’clock position at the right penile base. and repeated on the left. An additional 10 mL in the circumferential fashion around the penile base to anesthetize the remainder of the penile shaft. I place a straight Carmalt ball clamp over the phimotic foreskin at the 12 o’clock position and allowered this to remain clamped for 2 minutes. Metzenbaum scissors were used to incise the tissue approximately for—- allowing for full exposure of glans, Hemostasis was adequate.

patient is 42 years old. Is this considered CPT code 54150 or 54161?

Medical Billing and Coding Forum