How To Use CPT Code 54344

CPT 54344 describes the repair of complications that may arise from surgery for hypospadias, a condition where the urethral opening of the penis is abnormally located. 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 54344?

CPT 54344 can be used to describe the repair of complications that may occur as a result of surgery for hypospadias. This procedure involves mobilizing skin flaps and performing a urethroplasty with a flap or patch graft to address issues such as fistula, stricture, or diverticula.

2. Official Description

The official description of CPT code 54344 is: ‘Repair of hypospadias complication(s) (ie, fistula, stricture, diverticula); requiring mobilization of skin flaps and urethroplasty with flap or patch graft.’

3. Procedure

1. The provider begins by assessing the patient’s condition and determining the need for repair of hypospadias complications.
2. After appropriate preparation and anesthesia, the provider mobilizes skin flaps to access the affected area.
3. A urethroplasty is performed using a flap or patch graft to address the specific complications, such as fistula, stricture, or diverticula.
4. The provider carefully sutures any fistula to close it or repairs a urethral stricture by dilating it with the use of a catheter.
5. If diverticula are present, the provider mobilizes, dissects, and sutures them to repair the affected area.
6. The procedure may involve excising a stricture and using a graft or flap to cover any defects.
7. The provider ensures hemostasis and completes the repair.

4. Qualifying circumstances

CPT 54344 is used for patients who have undergone previous surgery for hypospadias and have developed complications such as fistula, stricture, or diverticula. The procedure requires the mobilization of skin flaps and the use of a flap or patch graft for urethroplasty. It is important to note that this code is specific to the repair of hypospadias complications and should not be used for other procedures or conditions.

5. When to use CPT code 54344

CPT code 54344 should be used when a provider is performing a repair procedure for complications arising from previous surgery for hypospadias. It is important to ensure that the procedure involves the mobilization of skin flaps and the use of a flap or patch graft for urethroplasty. This code should not be used for other repair procedures or conditions.

6. Documentation requirements

To support a claim for CPT 54344, the provider must document the following information:

• Patient’s diagnosis of hypospadias and the presence of complications
• Description of the specific complications being addressed (fistula, stricture, diverticula)
• Details of the procedure, including the mobilization of skin flaps and the use of a flap or patch graft for urethroplasty
• Any additional procedures performed, such as excision of a stricture or repair of diverticula
• Documentation of hemostasis and completion of the repair
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 54344, ensure that the procedure meets the criteria for repair of hypospadias complications requiring mobilization of skin flaps and urethroplasty with a flap or patch graft. It is important to accurately document the procedure and provide the necessary supporting documentation. CPT code 54344 should not be reported with other codes unless additional procedures unrelated to the repair of hypospadias complications are performed.

8. Historical information

CPT 54344 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 repair procedure for a patient who developed a fistula as a complication of previous hypospadias surgery.
2. A patient presents with a stricture resulting from previous hypospadias surgery, and the provider performs a repair procedure using a flap or patch graft.
3. A provider addresses diverticula that developed as a complication of previous hypospadias surgery by mobilizing skin flaps and performing a urethroplasty with a flap or patch graft.
4. A patient requires a repair procedure for multiple complications, including fistula, stricture, and diverticula, resulting from previous hypospadias surgery.
5. A provider performs a repair procedure for a patient who developed a fistula and a stricture as complications of previous hypospadias surgery.
6. A patient presents with diverticula and a stricture resulting from previous hypospadias surgery, and the provider performs a repair procedure using a flap or patch graft.
7. A provider addresses a fistula and diverticula that developed as complications of previous hypospadias surgery by mobilizing skin flaps and performing a urethroplasty with a flap or patch graft.
8. A patient requires a repair procedure for multiple complications, including fistula and diverticula, resulting from previous hypospadias surgery.