How To Use CPT Code 54115

CPT 54115 describes the removal of a foreign body from the deep tissues of the penis. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 54115?

CPT 54115 is used to describe the surgical removal of a foreign body from the deep tissues of the penis. This code is specifically for cases where the foreign body, such as a penile implant or any other object, is located within the deeper tissues of the penis and requires excision.

2. Official Description

The official description of CPT code 54115 is: ‘Removal of foreign body from deep penile tissue (e.g., plastic implant).’

3. Procedure

1. The patient is appropriately prepped and anesthetized for the procedure.
2. The provider makes an incision in the penis through the deeper tissues.
3. The provider excises down through the underlying tissue to access the foreign body.
4. The provider identifies and removes the penile implant or foreign body.
5. Once the removal is complete, the provider closes the incision with sutures.

4. Qualifying circumstances

CPT 54115 is used when a foreign body, such as a penile implant or any other object, is located within the deep tissues of the penis and requires surgical removal. This code is not appropriate for the removal of external rings or objects that are not within the deeper tissues of the penis. In such cases, an unlisted procedure code may be used.

5. When to use CPT code 54115

CPT code 54115 should be used when a foreign body is located within the deep tissues of the penis and requires surgical removal. It is important to ensure that the foreign body is within the deeper tissues and not external or superficial. If the foreign body is not within the deep tissues, an appropriate alternative code should be used.

6. Documentation requirements

To support a claim for CPT 54115, the provider must document the following information:

• Description of the foreign body and its location within the deep tissues of the penis
• Details of the procedure, including the incision made, excision of tissues, and removal of the foreign body
• Any complications or additional procedures performed
• Post-operative care instructions
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 54115, ensure that the procedure involves the removal of a foreign body from the deep tissues of the penis. It is important to accurately document the procedure and provide any necessary supporting documentation. Additionally, be aware of any specific guidelines or requirements from the payer regarding the use of this code.

8. Historical information

CPT 54115 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 removes a penile implant from the deep tissues of the penis.
2. A foreign body, such as a plastic fragment, is excised from the deeper tissues of the penis.
3. A patient undergoes surgery to remove a misplaced object from the deep tissues of the penis.
4. A provider performs a procedure to remove a foreign body, such as a broken piece of a penile implant, from the deep tissues of the penis.
5. A patient undergoes excision of a foreign body, such as a shard of metal, from the deeper tissues of the penis.
6. A provider removes a plastic implant from the deep tissues of the penis during a surgical procedure.
7. A foreign body, such as a bone fragment, is excised from the deeper tissues of the penis.
8. A patient undergoes surgery to remove a misplaced object from the deep tissues of the penis.
9. A provider performs a procedure to remove a foreign body, such as a broken piece of a penile implant, from the deep tissues of the penis.
10. A patient undergoes excision of a foreign body, such as a shard of metal, from the deeper tissues of the penis.