How To Use CPT Code 54304

CPT 54304 describes a surgical procedure performed on the penis to correct a condition called chordee or to repair hypospadias. This article will provide an overview of CPT code 54304, including its official description, the procedure involved, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and similar codes.

1. What is CPT Code 54304?

CPT 54304 is a code used to describe a surgical operation on the penis. It is performed to correct chordee, which is an abnormal curvature of the penis, or to repair hypospadias, a condition where the opening of the urethra is located under the penis. The procedure may involve the transplantation of prepuce (foreskin) and/or skin flaps to address the defect created during the operation.

2. Official Description

The official description of CPT code 54304 is: ‘Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce and/or skin flaps.’

3. Procedure

1. The provider begins by making an incision at the site of the deformity on the penis.
2. Various techniques may be employed to correct the defect, such as removing excess fibrous tissues, excising the prepuce (foreskin), or equalizing the length of the penis on both sides.
3. If hypospadias is present, the provider performs the first stage of the repair by dividing the glans penis in the midline to the tip.
4. The provider then unfolds the dorsal foreskin, divides it in the midline, and performs a midline closure.
5. A Foley catheter is inserted to drain the bladder.
6. To cover the defect created during the procedure, the provider may transplant a free or flap skin graft of foreskin to the operative site.
7. The urethral opening on the anterior shaft of the penis is left for final repair in a second stage procedure.
8. The incision is closed in layers using sutures, and a dressing is applied.
9. An artificial erection may be created using a band and saline injection to assess the effectiveness of the procedure in reducing the curvature of the penis.

4. Qualifying circumstances

CPT 54304 is performed on patients with chordee or hypospadias. The procedure is typically carried out by a provider who is skilled in plastic surgery. The transplantation of prepuce and/or skin flaps may be necessary depending on the specific case. It is important to note that the procedure is only performed when medically necessary to correct the identified condition.

5. When to use CPT code 54304

CPT code 54304 should be used when a surgical correction of chordee or the first stage of hypospadias repair is performed. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the transplantation of prepuce and/or skin flaps is not performed, a different code may be more appropriate.

6. Documentation requirements

To support a claim for CPT code 54304, the provider must document the following information:

• The patient’s diagnosis of chordee or hypospadias
• The specific details of the procedure performed, including any transplantation of prepuce and/or skin flaps
• The date of the surgery
• The duration of the procedure
• Any additional procedures or treatments performed during the same session
• Any complications or unexpected findings
• The provider’s signature

7. Billing guidelines

When billing for CPT code 54304, it is important to ensure that the procedure performed aligns with the code description. The provider should be skilled in plastic surgery and have the necessary qualifications to perform the operation. It is also important to follow any specific guidelines provided by the payer or insurance company. Additionally, it is important to review any bundling or unbundling rules that may apply to the procedure.

8. Historical information

CPT code 54304 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A plastic surgeon performing a surgical correction of chordee in a patient with an abnormal curvature of the penis.
2. A urologist performing the first stage of hypospadias repair in an infant with an underdeveloped urethral opening.
3. A reconstructive surgeon transplanting prepuce and skin flaps during a procedure to correct hypospadias in a young child.
4. A pediatric urologist performing a surgical correction of chordee in a teenager with a congenital penile deformity.
5. A plastic surgeon performing the first stage of hypospadias repair in an adult patient with a urethral opening located under the penis.
6. A urological surgeon performing a surgical correction of chordee in a patient with a history of penile trauma.
7. A reconstructive surgeon performing the first stage of hypospadias repair in a young boy with a congenital urethral abnormality.
8. A pediatric urologist transplanting prepuce and skin flaps during a procedure to correct hypospadias in an infant.