How To Use CPT Code 54160

CPT 54160 describes the surgical excision of the foreskin in a newborn using a technique other than a clamp, device, or dorsal slit. 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 54160?

CPT 54160 can be used to describe the surgical excision of the foreskin in a newborn who is 28 days old or less. This procedure is performed using a technique other than a clamp, device, or dorsal slit. It is important to note that modifier 63 should not be reported in conjunction with CPT 54160.

2. Official Description

The official description of CPT code 54160 is: ‘Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less).’ It is important to remember not to report modifier 63 with this code.

3. Procedure

1. The newborn, who is 28 days old or less, is positioned on their back or in a molded plastic seat.
2. The arms and legs of the newborn are securely strapped down to prevent any unwanted movement during the procedure.
3. The provider prepares the skin of the perineum and thighs with Betadine® or pHisoHex® liquid antiseptic.
4. The area is draped in a sterile fashion to maintain a clean surgical field.
5. A numbing cream or local dorsal penile or ring anesthetic block, or both, may be administered to ensure the comfort of the newborn.
6. The provider selects a technique other than a clamp, device, or dorsal slit to remove the foreskin.
7. One technique involves freeing the prepuce from the glans and pulling it out, placing locking forceps across the prepuce, and excising the skin flush to the forceps.
8. Another technique involves retracting the prepuce over the glans and making a circumferential incision around the shaft of the penis, then making another circumferential incision in the same position as the first one. A longitudinal incision is made between the two circumferential ones, and the strip of skin is removed.
9. The provider may also choose to include the frenulum in the excision or cut it separately.
10. Once the excision is complete, the provider applies petroleum jelly over the wound and wraps the penis in gauze.

4. Qualifying circumstances

CPT 54160 is performed on newborns who are 28 days old or less and require surgical excision of the foreskin. The procedure is done using a technique other than a clamp, device, or dorsal slit. It is important to note that modifier 63 should not be reported with this code.

5. When to use CPT code 54160

CPT code 54160 should be used when performing surgical excision of the foreskin in a newborn who is 28 days old or less. This code is appropriate when a technique other than a clamp, device, or dorsal slit is used. It is important to remember not to report modifier 63 with this code.

6. Documentation requirements

To support a claim for CPT 54160, the provider must document the following information:

• Newborn’s age (28 days or less)
• Details of the technique used for surgical excision
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures performed, such as including or excluding the frenulum
• Any anesthesia administered
• Post-procedure care instructions
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 54160, ensure that the procedure is performed on a newborn who is 28 days old or less and that a technique other than a clamp, device, or dorsal slit is used. Modifier 63 should not be reported with this code. It is important to follow the specific guidelines provided by the payer to ensure accurate billing and reimbursement.

8. Historical information

CPT 54160 was added to the Current Procedural Terminology system on January 1, 1990. On January 1, 2007, the code description was changed to specify ‘neonate’ instead of ‘newborn’.

9. Examples

1. A provider performs surgical excision of the foreskin in a newborn using a technique other than a clamp, device, or dorsal slit.
2. A newborn undergoes surgical excision of the foreskin using a technique other than a clamp, device, or dorsal slit.
3. A provider performs circumcision on a newborn who is 28 days old or less, using a technique other than a clamp, device, or dorsal slit.
4. A newborn receives surgical excision of the foreskin using a technique other than a clamp, device, or dorsal slit.
5. A provider performs surgical removal of the foreskin in a newborn using a technique other than a clamp, device, or dorsal slit.
6. A newborn undergoes surgical removal of the foreskin using a technique other than a clamp, device, or dorsal slit.
7. A provider performs circumcision on a newborn who is 28 days old or less, using a technique other than a clamp, device, or dorsal slit.
8. A newborn receives surgical removal of the foreskin using a technique other than a clamp, device, or dorsal slit.
9. A provider performs surgical excision of the foreskin in a newborn using a technique other than a clamp, device, or dorsal slit.