How To Use CPT Code 54163

CPT 54163 describes the procedure for repairing an incomplete circumcision. 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 54163?

CPT 54163 can be used to describe the surgical procedure performed to repair an incomplete circumcision. This code is used when the provider removes excessive residual foreskin left over from a previous circumcision, primarily to treat problems such as difficulty in urination and pain in penile erections.

2. Official Description

The official description of CPT code 54163 is: ‘Repair incomplete circumcision.’

3. Procedure

1. After the patient is appropriately prepped and anesthetized, the provider carefully frees the adhesions between the residual foreskin and the glans penis.
2. The provider then excises the residual foreskin and achieves hemostasis to stop any bleeding.
3. Sutures are placed to close the incised skin bridge, which is an adhesion formed if the initial circumcision did not heal properly.
4. Finally, the provider applies ointment and a gauze dressing to the area.

4. Qualifying circumstances

Patients eligible to receive CPT 54163 services are those who have undergone a previous circumcision that was incomplete and are experiencing problems such as difficulty in urination and pain in penile erections. The procedure is performed by a provider to repair the incomplete circumcision and alleviate these issues.

5. When to use CPT code 54163

CPT code 54163 should be used when a provider performs the surgical procedure to repair an incomplete circumcision. It is appropriate to bill this code when the patient has documented symptoms related to the incomplete circumcision and the procedure is performed to address those symptoms.

6. Documentation requirements

To support a claim for CPT 54163, the provider must document the following information:

• Patient’s symptoms related to the incomplete circumcision
• Details of the procedure performed, including the steps taken to repair the incomplete circumcision
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 54163, ensure that the procedure is performed to repair an incomplete circumcision. It is important to use the appropriate diagnosis code to support medical necessity. CPT code 54162 for lysis of penile adhesions is included and bundled into CPT 54163, as lysis of adhesions is part of the circumcision procedure.

8. Historical information

CPT 54163 was added to the Current Procedural Terminology system on January 1, 2002. There have been no updates to the code since its addition.

9. Examples

1. A provider performs CPT 54163 to repair an incomplete circumcision in a patient who is experiencing pain during penile erections.
2. A patient presents with difficulty in urination due to an incomplete circumcision, and the provider performs CPT 54163 to address the issue.
3. A provider performs CPT 54163 on a patient who had a previous circumcision that did not heal properly, resulting in residual foreskin causing discomfort during urination.
4. A patient undergoes CPT 54163 to repair an incomplete circumcision that is causing pain and difficulty in maintaining penile hygiene.
5. A provider performs CPT 54163 on a patient who is experiencing recurrent infections due to an incomplete circumcision.
6. A patient seeks treatment for discomfort and pain during penile erections caused by an incomplete circumcision, and the provider performs CPT 54163 to address the issue.
7. A provider performs CPT 54163 on a patient who had a previous circumcision that resulted in an adhesion, causing pain and discomfort during urination.
8. A patient undergoes CPT 54163 to repair an incomplete circumcision that is causing psychological distress and affecting their quality of life.
9. A provider performs CPT 54163 on a patient who is experiencing recurrent inflammation and irritation due to an incomplete circumcision.
10. A patient seeks treatment for difficulty in maintaining penile hygiene caused by an incomplete circumcision, and the provider performs CPT 54163 to address the issue.