How To Use CPT Code 54161

CPT 54161 refers to the surgical excision of the foreskin in patients older than 28 days using a technique other than clamp, device, or dorsal slit. This article will cover the description, procedure, qualifying circumstances, billing guidelines, documentation requirements, historical information, similar codes, and examples of CPT 54161.

1. What is CPT 54161?

CPT 54161 is a medical procedure code used to describe the surgical excision of the foreskin in patients older than 28 days of age, utilizing a technique other than clamp, device, or dorsal slit. This code is used by medical professionals to accurately document and bill for this specific type of circumcision procedure.

2. 54161 CPT code description

The official description of CPT code 54161 is: “Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age.”

3. Procedure

The 54161 CPT code procedure involves the following steps:

1. The patient, older than 28 days, is placed on their back or in a molded plastic seat, with arms and legs secured to prevent movement during the procedure.
2. The skin of the perineum and thighs is prepared with liquid antiseptic, and the area is draped in a sterile fashion.
3. A numbing cream or local dorsal penile or ring anesthetic block, or both cream and block, may be administered.
4. The provider frees the prepuce from the glans and pulls it out from the glans, places locking forceps across the prepuce, and excises the skin flush to the forceps. Alternatively, the provider can retract the prepuce over the glans and make a circumferential incision around the shaft of the penis, then pull the prepuce back over the glans and make another circumferential incision around the shaft in the same position as the first one.
5. The provider makes a longitudinal incision between the two circumferential ones, removes the strip of skin, and sutures the raw edges.
6. The provider may include the frenulum in the original excision or cut it separately.
7. Upon completion of the procedure, the provider applies petroleum jelly over the wound and wraps the penis in gauze.

4. Qualifying circumstances

Patients eligible to receive CPT code 54161 services are those older than 28 days of age who require circumcision for medical reasons or personal preference. Medical reasons may include potential preventive benefits, such as reducing the risk of urinary tract infection in the first year of life and reducing the risk of acquiring or transmitting sexually transmitted infections. Adult patients may undergo the procedure to treat conditions such as phimosis, a condition in which the foreskin is too tight to be pulled back over the head or glans of the penis.

5. When to use CPT code 54161

It is appropriate to bill the 54161 CPT code when the circumcision procedure is performed on a patient older than 28 days of age using a surgical excision technique other than clamp, device, or dorsal slit. This code should be used to accurately document and bill for this specific type of circumcision procedure.

6. Documentation requirements

To support a claim for CPT 54161, the following information needs to be documented:

• Patient’s age at the time of the procedure
• Medical necessity or reason for the circumcision
• Technique used for the surgical excision
• Details of the procedure, including anesthesia used and steps taken during the surgery
• Postoperative care instructions and follow-up appointments

7. Billing guidelines

When billing for CPT code 54161, it is essential to follow the appropriate guidelines and rules. Ensure that the patient’s age and the technique used for the surgical excision are accurately documented. Additionally, it is crucial to provide a detailed description of the procedure, including the anesthesia used and the steps taken during the surgery. Following these guidelines will help ensure accurate billing and reimbursement for the services provided.

8. Historical information

CPT 54161 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2007, with the previous descriptor being “Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn.”

9. Similar codes to CPT 54161

Five similar codes to CPT 54161 differentiate as follows:

• CPT 54150: Circumcision using a clamp or other devices with regional dorsal penile or ring block anesthetic for patients 28 days old or younger.
• CPT 54160: Circumcision using a surgical excision technique other than clamp, device, or dorsal slit for patients 28 days old or younger.
• CPT 54162: Circumcision using a clamp or other devices with regional dorsal penile or ring block anesthetic for patients older than 28 days of age.
• CPT 54163: Circumcision using a dorsal slit technique for patients older than 28 days of age.
• CPT 54164: Circumcision revision for patients older than 28 days of age.

10. Examples

Here are 10 detailed examples of CPT code 54161 procedures:

1. A 6-month-old infant undergoing circumcision due to recurrent urinary tract infections.
2. A 3-year-old child undergoing circumcision for medical reasons, such as phimosis.
3. A 16-year-old adolescent undergoing circumcision for personal preference or cultural reasons.
4. An adult male undergoing circumcision to reduce the risk of acquiring or transmitting sexually transmitted infections.
5. A 45-year-old male undergoing circumcision to treat a condition such as paraphimosis.
6. A 30-year-old male undergoing circumcision for cosmetic reasons.
7. A 25-year-old male undergoing circumcision as part of a religious conversion process.
8. A 35-year-old male undergoing circumcision to improve hygiene and reduce the risk of penile cancer.
9. A 50-year-old male undergoing circumcision to treat a condition such as balanitis.
10. A 40-year-old male undergoing circumcision as part of a treatment plan for erectile dysfunction.