How To Use CPT Code 54318

CPT 54318 describes a surgical procedure used to release the penis from the scrotum in the third stage of hypospadias repair. 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 54318?

CPT 54318 is a code used to describe a surgical procedure performed to release the penis from the scrotum during the third stage of hypospadias repair. This procedure involves detaching temporary sutures that were previously put in place during the second stage of the repair. The purpose of this procedure is to correct the positioning of the urethral opening in males with hypospadias, ensuring that it is at the tip of the penis rather than under it.

2. Official Description

The official description of CPT code 54318 is: ‘Urethroplasty for third stage hypospadias repair to release penis from scrotum (eg, third stage Cecil repair).’ This code specifically refers to the surgical procedure performed during the third stage of hypospadias repair to release the penis from the scrotum.

3. Procedure

1. After appropriate prepping and anesthesia, the provider makes an incision and detaches the temporary sutures between the penis and scrotum that were previously placed during the second stage of hypospadias repair.
2. If necessary, a Foley catheter may be inserted into the bladder to divert urine.
3. The provider then closes the incision with sutures.

4. Qualifying circumstances

CPT 54318 is performed on patients who require the third stage of hypospadias repair. Hypospadias is a condition present from birth in some males where the opening of the urethra is located under the penis instead of at the tip. The procedure is performed by a qualified healthcare professional to correct the positioning of the urethral opening and release the penis from the scrotum. It is important to note that this procedure is specific to the third stage of hypospadias repair.

5. When to use CPT code 54318

CPT code 54318 should be used when performing the third stage of hypospadias repair to release the penis from the scrotum. It is important to ensure that the procedure is performed specifically for this purpose and that the patient meets the qualifying circumstances for hypospadias repair. This code should not be used for other procedures or stages of hypospadias repair.

6. Documentation requirements

To support a claim for CPT code 54318, the healthcare professional must document the following information:

• Patient’s diagnosis of hypospadias
• Details of the procedure performed, including the release of the penis from the scrotum
• Date of the procedure
• Any additional procedures or interventions performed during the same session
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT code 54318, it is important to ensure that the procedure meets the specific criteria outlined in the official description. This includes performing the procedure during the third stage of hypospadias repair and releasing the penis from the scrotum. It is also important to follow any additional guidelines provided by the payer or coding guidelines. CPT code 54318 should not be reported with other codes unless additional procedures or interventions were performed during the same session.

8. Historical information

CPT code 54318 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 qualified healthcare professional performs the third stage of hypospadias repair, releasing the penis from the scrotum, for a patient with hypospadias.
2. During the third stage of hypospadias repair, the provider detaches the temporary sutures between the penis and scrotum, correcting the positioning of the urethral opening.
3. A patient with hypospadias undergoes the third stage of repair, where the provider releases the penis from the scrotum to ensure proper positioning of the urethral opening.
4. As part of the third stage of hypospadias repair, the healthcare professional performs a procedure to release the penis from the scrotum, correcting the abnormal positioning of the urethral opening.
5. During the third stage of hypospadias repair, the provider performs a surgical procedure to release the penis from the scrotum, ensuring that the urethral opening is at the tip of the penis.
6. A patient with hypospadias undergoes the third stage of repair, where the healthcare professional releases the penis from the scrotum, correcting the abnormal positioning of the urethral opening.
7. The provider performs the third stage of hypospadias repair, releasing the penis from the scrotum, for a patient with a congenital urethral abnormality.
8. During the third stage of hypospadias repair, the healthcare professional releases the penis from the scrotum, correcting the abnormal positioning of the urethral opening in a patient with hypospadias.
9. A qualified healthcare professional performs a surgical procedure to release the penis from the scrotum as part of the third stage of hypospadias repair for a patient with this congenital condition.
10. During the third stage of hypospadias repair, the provider releases the penis from the scrotum, ensuring that the urethral opening is properly positioned at the tip of the penis.