Penis

For destruction of lesion(s) (54050-54065), documentation should include the method

of
destruction (for example, chemical, laser surgery, or surgical excision). This
selection varies
from other areas in the CPT system because the amount of physician work to perform
the dif
ferent types of destruction varies. Code 54065 should be reported, instead of 54050
through
54060, when the physician determines that the destruction, by any method, is
extensive.

For correct assignment of repair code , the type of repair (such as plastic), the
stage (second,
third), and any other procedure(s) performed should be identified.

To code a circumcision, the operative report should be used to distingui h between

a
circumcision by clamp and/or other device or a surgical incision other than a
clamp, device, or
dorsal slit. In addition, correct code assignment is based on whether the patient
is a newborn
or other than a newborn. In cases where a revision of a past circumcision is
required, CPT
provides code 54162 for lysis or excision of penile postcircumcision adhesions and
code 54163
for repair of an incomplete circumcision.

Coders may find coding newborn circumcision done in the hospital to be challenging.
The
typical service provided by a pediatrician on the second day of life is a
subsequent newborn
exam (not related to the circumcision), the circumcision by the chosen method, and
a ring
block or dorsal nerve block as regional anesthesia. If the surgical circumcision is
performed,
this case would be coded as:

99462-25 Subsequent hospital care, for the evaluation and management of a normal
newborn, per day

54160-47 Circumcision, surgical excision other than clamp, device or dorsal slit;
neonate (28 days of age or less)

64450 Injection, anesthetic agent; other peripheral nerve or branch