How To Use CPT Code 54135

CPT 54135 describes the surgical procedure of amputation of the penis, radical; in continuity with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes. 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 54135?

CPT 54135 is a code used to describe a surgical procedure known as radical amputation of the penis. This procedure involves the complete removal of the penis along with the lymph nodes in the groin area. It is typically performed to treat extensive or non-responsive cancer of the penis.

2. Official Description

The official description of CPT code 54135 is: ‘Amputation of penis, radical; in continuity with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes.’

3. Procedure

1. The surgeon 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. The fascia of the penis is then incised, and the urethra is dissected. A vessel loop is placed around the urethra to draw it back while the surgeon continues to dissect the penis.
3. The suspensory ligaments and vessels of the penis are located, clamped, cut, and tied 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, and the incision is closed. A catheter is inserted into the new urethral opening.
7. To remove the surrounding lymph nodes, the surgeon incises the pubic bone to the pelvic bone and carefully removes the node packet from the surrounding muscles, blood vessels, and nerves.
8. The thigh muscle is then rotated over the defect, secured with sutures, and the wound is closed over the external drains.
9. A low abdominal incision is made to identify, isolate, and remove the deep pelvic lymph nodes.
10. Finally, the wounds are closed and dressed.

4. Qualifying circumstances

CPT 54135 is performed on patients with extensive or non-responsive cancer of the penis. The procedure involves the complete removal of the penis along with the lymph nodes in the groin area. It is typically performed when standard treatments have not been effective or when the size and depth of the cancer are extensive.

5. When to use CPT code 54135

CPT code 54135 should be used when performing a radical amputation of the penis in continuity with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes. 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 54135, the surgeon must document the following information:

• Patient’s diagnosis and the need for radical amputation of the penis
• Details of the surgical procedure performed, including the incisions made, lymph nodes removed, and any complications encountered
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures performed in conjunction with CPT 54135
• Signature of the surgeon performing the procedure

7. Billing guidelines

When billing for CPT 54135, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the details of the procedure and any additional procedures performed. CPT code 54135 should not be reported with separate lymphadenectomy codes (38760-38770).

8. Historical information

CPT code 54135 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 in continuity with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes.
2. A surgeon performs a radical amputation of the penis in continuity with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes, on a patient with non-responsive cancer of the penis.
3. A radical amputation of the penis in continuity with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes, is performed on a patient with extensive cancer of the penis that is not responding to standard treatment.
4. A surgeon performs a radical amputation of the penis in continuity with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes, on a patient with extensive and deep cancer of the penis.
5. A patient with non-responsive cancer of the penis undergoes a radical amputation of the penis in continuity with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes.
6. A surgeon performs a radical amputation of the penis in continuity with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes, on a patient with extensive and non-responsive cancer of the penis.