How To Use CPT Code 54336

CPT 54336 describes a one-stage perineal hypospadias repair procedure that involves extensive dissection to correct chordee and urethroplasty using a skin graft tube and/or island flap. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 54336?

CPT 54336 is a code used to describe a surgical procedure performed to correct hypospadias in the perineal region. The procedure involves extensive dissection to correct chordee, which is an abnormal curvature of the penis. Additionally, the provider performs urethroplasty using a skin graft tube or island flap as part of the procedure.

2. Official Description

The official description of CPT code 54336 is: ‘One-stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap.’

3. Procedure

1. The provider begins by making an incision near the scrotal side of the penis and around the meatus.
2. A wide rectangular flap is prepared from preputial skin and sutured together to form a tube, which will be used as part of the urethra.
3. The resultant tube flap is secured in place between the urethral opening in the perineum and an opening created at the tip of the penis.
4. The provider covers the hypospadiac meatus with the skin flap.
5. If necessary, a circumcision may be performed at the end of the procedure to ensure smooth movement of the glans through the prepuce.
6. The incision is closed with sutures.

4. Qualifying circumstances

CPT 54336 is performed on patients with hypospadias, a condition in which the opening of the urethra is located under the penis instead of at the tip. The procedure requires extensive dissection to correct chordee, which is often associated with hypospadias. The use of a skin graft tube and/or island flap is necessary for urethroplasty. This procedure is typically performed in cases where other less invasive treatments have been unsuccessful.

5. When to use CPT code 54336

CPT code 54336 should be used when a one-stage perineal hypospadias repair is performed, requiring extensive dissection to correct chordee and urethroplasty using a skin graft tube and/or island flap. It is important to ensure that the procedure meets the specific criteria outlined in the code description before reporting it.

6. Documentation requirements

To support a claim for CPT 54336, the provider must document the following information:

• Patient’s diagnosis of hypospadias
• Details of the extensive dissection performed
• Description of the chordee correction
• Documentation of the urethroplasty using a skin graft tube and/or island flap
• Date of the procedure
• Any additional relevant information or complications encountered during the surgery

7. Billing guidelines

When billing for CPT 54336, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the details of the surgery and any additional procedures performed. Additionally, be aware of any specific payer guidelines or requirements for reporting this code.

8. Historical information

CPT 54336 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 perineal hypospadias repair on an infant, correcting chordee and performing urethroplasty using a skin graft tube.
2. A patient with hypospadias undergoes a surgical procedure to correct the abnormal curvature of the penis and repair the urethra with an island flap.
3. A teenager with hypospadias undergoes extensive dissection to correct chordee and urethroplasty using a combination of a skin graft tube and island flap.
4. A provider performs a one-stage perineal hypospadias repair on an adult patient, utilizing a skin graft tube for urethroplasty.
5. A child with hypospadias undergoes a surgical procedure to correct chordee and repair the urethra using an island flap.
6. A provider performs a one-stage perineal hypospadias repair on a young boy, correcting chordee and utilizing a skin graft tube for urethroplasty.
7. An adult patient with hypospadias undergoes extensive dissection to correct chordee and urethroplasty using a combination of a skin graft tube and island flap.
8. A provider performs a one-stage perineal hypospadias repair on a teenager, utilizing an island flap for urethroplasty.
9. A child with hypospadias undergoes a surgical procedure to correct the abnormal curvature of the penis and repair the urethra using a skin graft tube.
10. A provider performs a one-stage perineal hypospadias repair on an infant, correcting chordee and performing urethroplasty using an island flap.