How To Use CPT Code 54125

CPT 54125 describes the complete amputation of the penis. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 54125?

CPT 54125 is used to describe the surgical procedure of completely removing the penis. This procedure is typically performed to treat a severe injury or disease of the penis. The provider makes an incision from above the penis to the base of the shaft and carries the incision forward to near the middle of the scrotum. The underlying structures are carefully divided, and a new meatus is created between the scrotum and anus. The urethra is brought through this opening, and an on-off valve in the urethra above the penis level helps control the urination process. The rest of the tissues and skin are closed with sutures, and a drain is placed in the scrotum for fluid drainage. A catheter is left in the bladder, and the incision is closed with sutures.

2. Official Description

The official description of CPT code 54125 is: ‘Amputation of penis; complete.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision from above the penis to the base of the shaft and carries the incision forward to near the middle of the scrotum.
3. The provider carefully divides the underlying structures and creates a new meatus between the scrotum and anus.
4. The urethra is brought through this opening, and an on-off valve in the urethra above the penis level helps control the urination process.
5. The provider closes the rest of the tissues and skin with sutures and places a drain in the scrotum to allow drainage of any fluid.
6. A catheter is left in the bladder, and the incision is closed with sutures.

4. Qualifying circumstances

CPT 54125 is performed when there is a severe injury or disease of the penis that requires complete amputation. This procedure is typically reserved for cases where other treatment options have been exhausted or are not feasible. It is important to note that partial amputation of the penis is coded differently (CPT 54120).

5. When to use CPT code 54125

CPT code 54125 should be used when the provider performs a complete amputation of the penis due to a severe injury or disease. It is important to ensure that the procedure meets the criteria outlined in the official description.

6. Documentation requirements

To support a claim for CPT 54125, the provider must document the following information:

• Reason for the complete amputation of the penis
• Details of the surgical procedure, including the incision, division of underlying structures, creation of a new meatus, and closure of tissues and skin
• Placement of a drain in the scrotum and a catheter in the bladder
• Any additional relevant information or complications

7. Billing guidelines

When billing for CPT 54125, ensure that the procedure performed meets the criteria outlined in the official description. It is important to follow the specific documentation requirements and guidelines provided by the payer. It is also important to note that CPT code 54125 is an inpatient-only procedure, meaning it is typically performed in a hospital setting and is not eligible for reimbursement in an outpatient setting.

8. Historical information

CPT 54125 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added to the Inpatient Only (IPO) list for Medicare reimbursement.

9. Examples

1. A patient undergoes a complete amputation of the penis due to penile cancer.
2. A severe injury to the penis requires a complete amputation to prevent further complications.
3. A patient with a rare disease undergoes a complete amputation of the penis as a last resort treatment option.
4. A provider performs a complete amputation of the penis due to a severe infection that cannot be effectively treated with other methods.
5. A patient with a recurrent penile abscess undergoes a complete amputation of the penis to prevent further complications.
6. A provider performs a complete amputation of the penis as part of a gender-affirming surgery for a transgender individual.
7. A patient with an advanced stage of penile cancer undergoes a complete amputation of the penis to remove all diseased tissue.
8. A severe trauma to the penis requires a complete amputation to ensure proper healing and prevent infection.
9. A patient with a rare congenital anomaly undergoes a complete amputation of the penis to improve their quality of life.
10. A provider performs a complete amputation of the penis as a life-saving measure in a case of severe penile gangrene.