How To Use CPT Code 54326

CPT 54326 describes a one-stage surgical procedure used to correct hypospadias, a condition where the opening of the urethra is located under the penis instead of at the tip. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 54326?

CPT 54326 is a code used to describe a one-stage surgical procedure for the repair of hypospadias. During this procedure, the provider corrects the abnormal positioning of the urethral opening by using local skin flaps and mobilizing the urethra. Additionally, the provider may perform a circumcision or address chordee, an abnormal curvature of the penis.

2. Official Description

The official description of CPT code 54326 is: ‘1-stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps and mobilization of urethra.’

3. Procedure

1. The provider begins by making an incision around the glans penis and carefully dissecting the skin, taking care not to damage the urethra.
2. An artificial erection may be created to assess the presence of chordee, and if necessary, the provider will excise any extra fibrous tissue to correct the abnormal curvature of the penis.
3. If circumcision is deemed necessary, the provider will perform the procedure.
4. The provider then mobilizes the urethra by dissecting it from the penile shaft.
5. Next, the provider makes an incision near the glans and another incision to release a flap of foreskin.
6. The soft tissue is molded to the distal urethra and sutured together, creating an extension of the urethra in a tube shape.
7. The foreskin is further divided to repair the defect created to extend the urethra.

4. Qualifying circumstances

CPT 54326 is used for patients with hypospadias, a congenital condition where the urethral opening is located on the underside of the penis. The procedure is performed to correct this abnormality and may also address chordee or involve circumcision. The provider must use local skin flaps and mobilize the urethra during the repair.

5. When to use CPT code 54326

CPT code 54326 should be used when a one-stage surgical procedure is performed to correct hypospadias, with or without chordee or circumcision. It is important to ensure that the procedure involves the use of local skin flaps and mobilization of the urethra. If the procedure does not meet these criteria, a different code should be used.

6. Documentation requirements

To support a claim for CPT 54326, the provider must document the following information:

• Patient’s diagnosis of hypospadias
• Details of the procedure performed, including the use of local skin flaps and mobilization of the urethra
• Any additional procedures performed, such as circumcision or correction of chordee
• Date of the procedure
• Any complications or unexpected findings
• Signature of the provider

7. Billing guidelines

When billing for CPT 54326, ensure that the procedure meets the criteria outlined in the official description. It is important to use the correct code for the specific procedure performed. If additional procedures, such as circumcision, are performed during the same session, they should be documented and billed separately. It is also important to follow any specific guidelines provided by the payer regarding the use of modifiers or reporting of multiple procedures.

8. Historical information

CPT 54326 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 provider performs a one-stage distal hypospadias repair on an infant, correcting the urethral opening and addressing chordee.
2. A surgeon performs a one-stage distal hypospadias repair on a child, using local skin flaps to reconstruct the urethra and performing circumcision.
3. A urologist performs a one-stage distal hypospadias repair on a teenager, correcting the urethral opening and addressing chordee without circumcision.
4. A pediatric surgeon performs a one-stage distal hypospadias repair on an infant, using local skin flaps to reconstruct the urethra and performing circumcision.
5. A reconstructive surgeon performs a one-stage distal hypospadias repair on an adult, correcting the urethral opening and addressing chordee without circumcision.
6. A urologist performs a one-stage distal hypospadias repair on a child, using local skin flaps to reconstruct the urethra and performing circumcision.
7. A pediatric surgeon performs a one-stage distal hypospadias repair on an infant, correcting the urethral opening and addressing chordee without circumcision.