How To Use CPT Code 54000

CPT 54000 describes the procedure of slitting the prepuce in a newborn to reduce narrowing and prevent withdrawal of the foreskin back over the head of the penis. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 54000?

CPT 54000 is used to describe the procedure of slitting the prepuce in a newborn to alleviate narrowing and prevent the foreskin from retracting over the head of the penis. This code is specifically for newborn patients and should not be used for patients other than newborns.

2. Official Description

The official description of CPT code 54000 is: ‘Slitting of prepuce, dorsal or lateral (separate procedure); newborn.’ It is important to note that modifier 63 should not be reported in conjunction with this code.

3. Procedure

1. When performing the procedure, the provider begins by appropriately prepping and anesthetizing the patient, who is a newborn.
2. The provider then uses forceps to grasp the prepuce and makes a stab incision at the lateral or dorsal side of the penis.
3. Using scissors, the provider carefully dissects the foreskin from the base and removes it.
4. Any bleeding that occurs during the procedure is controlled through the use of small linear sutures.

4. Qualifying circumstances

CPT 54000 is specifically used for newborn patients who require the slitting of the prepuce to address narrowing and prevent retraction of the foreskin. It is important to note that this code should not be used for patients other than newborns.

5. When to use CPT code 54000

CPT code 54000 should be used when performing the procedure of slitting the prepuce in a newborn to alleviate narrowing and prevent the foreskin from retracting over the head of the penis. It is important to ensure that the patient is a newborn and that the procedure is performed for the specified purpose.

6. Documentation requirements

To support a claim for CPT 54000, the provider must document the following information:

• The patient’s status as a newborn
• The need for the procedure to address narrowing and prevent foreskin retraction
• The specific approach used (dorsal or lateral)
• The date of the procedure
• Any additional details or complications encountered during the procedure

7. Billing guidelines

When billing for CPT 54000, it is important to ensure that the procedure is performed on a newborn patient. Modifier 63 should not be reported in conjunction with this code. Additionally, it is important to follow any specific billing guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 54000 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A provider performs the procedure of slitting the prepuce in a newborn to alleviate narrowing and prevent foreskin retraction.
2. During the procedure, the provider uses forceps to grasp the prepuce and makes an incision at the dorsal side of the penis.
3. Using scissors, the provider carefully dissects the foreskin from the base and removes it.
4. The provider controls any bleeding that occurs during the procedure through the use of small linear sutures.
5. Another provider performs the same procedure on a different newborn patient to address narrowing and prevent foreskin retraction.
6. During this procedure, the provider makes an incision at the lateral side of the penis.
7. The provider carefully dissects the foreskin from the base and removes it.
8. Any bleeding that occurs during the procedure is controlled through the use of small linear sutures.
9. A different provider performs the procedure on a newborn patient, using a different approach to address narrowing and prevent foreskin retraction.
10. During this procedure, the provider makes an incision at the dorsal side of the penis.