How To Use CPT Code 54111

CPT 54111 describes the excision of penile plaque (Peyronie disease) with a graft up to 5 cm in length. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 54111?

CPT 54111 can be used to describe the surgical procedure performed to remove plaque or abnormal fibrous tissues in the penis and replace it with a skin graft up to 5 cm in length. This procedure is typically done to correct Peyronie’s disease, a condition characterized by severe penile curves, pain during erection, and the presence of a lump in the shaft of the penis.

2. Official Description

The official description of CPT code 54111 is: ‘Excision of penile plaque (Peyronie disease); with graft to 5 cm in length.’

3. Procedure

1. The patient is prepared and anesthetized for the procedure.
2. The healthcare provider makes an incision around the penis and retracts the skin to expose the plaque.
3. The provider carefully excises the plaque or abnormal fibrous tissues underlying the corpus cavernosum region of the penis, preserving important nerves and small blood vessels.
4. A suitable skin or tissue graft measuring up to 5 cm in length is obtained from another part of the patient’s body.
5. The graft is placed on the penis to fill in the defect created by the excision of the plaque.
6. The provider closes the skin incision with sutures.

4. Qualifying circumstances

CPT 54111 is performed on patients with Peyronie’s disease, a condition characterized by the presence of plaque or hard lumps on the penis. The procedure is indicated when the patient experiences severe penile curves, pain during erection, and shortening of the penis. The patient must meet the criteria for surgical intervention, and the healthcare provider must determine that excision of the plaque and grafting is the appropriate treatment option.

5. When to use CPT code 54111

CPT code 54111 should be used when the excision of penile plaque and grafting procedure is performed to correct Peyronie’s disease. It is important to ensure that the length of the graft does not exceed 5 cm. This code should not be used for other penile excision procedures or grafting procedures unrelated to Peyronie’s disease.

6. Documentation requirements

To support a claim for CPT 54111, the healthcare provider must document the following information:

• Patient’s diagnosis of Peyronie’s disease
• Details of the excision procedure, including the size and location of the plaque
• Description of the graft used, including its length and source
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 54111, ensure that the excision of penile plaque and grafting procedure is performed according to the official description. It is important to accurately report the length of the graft used, as it should not exceed 5 cm. There are no specific guidelines regarding reporting CPT 54111 with other codes. However, it is important to follow any applicable bundling or unbundling rules and to provide appropriate documentation to support the medical necessity of the procedure.

8. Historical information

CPT 54111 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A patient with Peyronie’s disease undergoes an excision of penile plaque and grafting procedure to correct severe penile curves and pain during erection.
2. A healthcare provider performs an excision of penile plaque and grafting procedure on a patient with Peyronie’s disease, using a 4 cm skin graft to fill in the defect.
3. A patient presents with Peyronie’s disease and undergoes an excision of penile plaque and grafting procedure, with a 3 cm tissue graft obtained from the patient’s own body.
4. A healthcare provider performs an excision of penile plaque and grafting procedure on a patient with Peyronie’s disease, using a 5 cm skin graft harvested from a cadaver source.
5. A patient with Peyronie’s disease undergoes an excision of penile plaque and grafting procedure, with a 2 cm autogenous graft obtained through a separate incision.