How To Use CPT Code 54130

CPT 54130 describes the radical amputation of the penis, along with a bilateral inguinofemoral lymphadenectomy. 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 54130?

CPT 54130 can be used to describe the complete removal of the penis, including the surrounding lymph nodes in the groin areas. This procedure is typically performed to treat extensive or non-responsive cancer of the penis. It involves a radical amputation of the penis and a bilateral inguinofemoral lymphadenectomy.

2. Official Description

The official description of CPT code 54130 is: ‘Amputation of penis, radical; with bilateral inguinofemoral lymphadenectomy.’

3. Procedure

1. The provider begins by making a circular incision around the penis, starting above its base and extending around the shaft to near the midline of the scrotum.
2. Next, the provider incises the fascia of the penis and dissects the urethra, placing a vessel loop around it to draw it back.
3. The provider then locates and clamps the suspensory ligaments and vessels of the penis, cutting and tying them off.
4. A small circular incision is made in the perineum at the base of the penis below the scrotum, and a tunnel is created through the tissue.
5. The urethra is incised and pulled downward and through the tunnel, joining it to the perineum skin.
6. A drain is placed in the penectomy incision, which is then closed. A catheter is inserted into the new urethral opening.
7. To remove the surrounding lymph nodes, the provider incises the pubic bone to the pelvic bone and carefully removes the node packets from the surrounding muscles, blood vessels, and nerves on both sides of the groin.
8. The thigh muscles are rotated over the defects and secured with sutures.
9. Finally, the wounds are closed and dressed.

4. Qualifying circumstances

CPT 54130 is performed when the patient has extensive or non-responsive cancer of the penis that requires radical amputation and removal of the surrounding lymph nodes. The procedure is typically reserved for cases where standard treatments have not been effective or when the size and depth of the mass are significant. It is important to note that this procedure is performed by a qualified healthcare professional.

5. When to use CPT code 54130

CPT code 54130 should be used when a radical amputation of the penis is performed, along with a bilateral inguinofemoral lymphadenectomy. It is appropriate for cases of extensive or non-responsive cancer of the penis. This code should not be used for other procedures or conditions.

6. Documentation requirements

To support a claim for CPT 54130, the healthcare professional must document the following information:

• Patient’s diagnosis and the need for radical amputation and lymphadenectomy
• Details of the procedure, including the incisions made, tissues dissected, ligaments and vessels clamped and cut, and the joining of the urethra to the perineum skin
• Date and duration of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 54130, ensure that the procedure is performed by a qualified healthcare professional and includes both the radical amputation of the penis and the bilateral inguinofemoral lymphadenectomy. It is important to follow the specific guidelines and requirements of the payer when submitting the claim.

8. Historical information

CPT 54130 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.

9. Examples

1. A patient with extensive cancer of the penis undergoes a radical amputation of the penis and a bilateral inguinofemoral lymphadenectomy.
2. A provider performs a radical amputation of the penis and a bilateral inguinofemoral lymphadenectomy for a patient with non-responsive cancer of the penis.
3. A patient with a large and deep mass in the penis undergoes a radical amputation and lymphadenectomy.
4. A provider performs a radical amputation of the penis and a bilateral inguinofemoral lymphadenectomy for a patient with advanced cancer of the penis.
5. A patient with extensive cancer of the penis undergoes a radical amputation and removal of the surrounding lymph nodes.
6. A provider performs a radical amputation of the penis and a bilateral inguinofemoral lymphadenectomy for a patient with a non-responsive tumor in the penis.
7. A patient with a significant size and depth of the mass in the penis undergoes a radical amputation and lymphadenectomy.
8. A provider performs a radical amputation of the penis and a bilateral inguinofemoral lymphadenectomy for a patient with an extensive tumor in the penis.
9. A patient with non-responsive cancer of the penis undergoes a radical amputation and removal of the surrounding lymph nodes.
10. A provider performs a radical amputation of the penis and a bilateral inguinofemoral lymphadenectomy for a patient with an advanced tumor in the penis.