How To Use CPT Code 54015

CPT 54015 describes the procedure of incision and drainage of the penis, specifically for deep abscesses, cysts, or lesions. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 54015?

CPT 54015 is used to describe the incision and drainage procedure performed on the penis for deep abscesses, cysts, or lesions. This code is specifically used when the provider makes an incision in the penile tissue to drain the fluid and relieve pain, preventing further infection.

2. Official Description

The official description of CPT code 54015 is: ‘Incision and drainage of penis, deep.’ This code is used when the provider performs the procedure to drain deep abscesses, cysts, or lesions in the penile tissue.

3. Procedure

1. The provider prepares the patient for the procedure, typically by administering local anesthesia to numb the area.
2. Using a small incision, the provider accesses the penile tissue above the lesion.
3. The incision is extended down to the fascia and muscular level to fully expose the abscess, cyst, or lesion.
4. The provider carefully cuts into the cavity, allowing the fluid to drain out.
5. The cavity is thoroughly washed to ensure proper drainage and prevent infection.
6. Any bleeding is controlled using electrocautery, a surgical cutting instrument that uses heat generated from electrical current.
7. The external penile incision is closed in layers using absorbable sutures.

4. Qualifying circumstances

CPT 54015 is performed when a patient presents with a deep abscess, cyst, or lesion in the penile tissue that requires drainage. The procedure is typically done to prevent infection and relieve pain. It is important to note that this code specifically applies to deep abscesses, cysts, or lesions and not to skin and subcutaneous abscesses, which have their own range of CPT codes (10060-10160).

5. When to use CPT code 54015

CPT code 54015 should be used when the provider performs an incision and drainage procedure on the penis for deep abscesses, cysts, or lesions. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 54015, the provider must document the following information:

• Patient’s diagnosis indicating the presence of a deep abscess, cyst, or lesion
• Details of the procedure, including the specific location of the incision and the depth of the drainage
• Use of local anesthesia for patient comfort
• Thorough washing of the cavity to ensure proper drainage
• Control of any bleeding using electrocautery
• Method of closure for the external penile incision

7. Billing guidelines

When billing for CPT 54015, ensure that the procedure meets the criteria outlined in the code description. It is important to accurately document the details of the procedure and provide the necessary supporting documentation. Additionally, be aware of any specific billing guidelines or modifiers that may apply to this code.

8. Historical information

CPT 54015 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 an incision and drainage procedure on a patient with a deep abscess in the penile tissue.
2. A patient presents with a cyst in the penile tissue, and the provider performs an incision and drainage procedure to alleviate discomfort.
3. A provider performs an incision and drainage procedure on a patient with a deep lesion in the penile tissue to prevent infection.
4. A patient with a deep abscess in the penile tissue undergoes an incision and drainage procedure to relieve pain and promote healing.
5. A provider performs an incision and drainage procedure on a patient with a deep abscess in the penile tissue caused by infection.
6. A patient with a deep cyst in the penile tissue undergoes an incision and drainage procedure to remove the fluid and prevent further complications.
7. A provider performs an incision and drainage procedure on a patient with a deep lesion in the penile tissue to facilitate healing and prevent infection.
8. A patient presents with a deep abscess in the penile tissue, and the provider performs an incision and drainage procedure to alleviate pain and promote recovery.
9. A provider performs an incision and drainage procedure on a patient with a deep abscess in the penile tissue caused by a bacterial infection.
10. A patient with a deep cyst in the penile tissue undergoes an incision and drainage procedure to relieve discomfort and prevent complications.