How To Use CPT Code 54438

CPT 54438 describes the procedure for replantation of a completely amputated penis, including urethral repair. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 54438?

CPT 54438 can be used to report the surgical procedure for the replantation of a completely amputated penis, including the repair of the urethra. This code is used when a provider reattaches the penis and repairs the urethra after its complete amputation or loss due to causes such as an avulsion or crush injury.

2. Official Description

The official description of CPT code 54438 is: ‘Replantation, penis, complete amputation including urethral repair.’ This code should be used when the provider performs the complete replantation of a completely amputated penis and also repairs the urethra. It is important to note that this code should not be used for the repair of incomplete penile amputation or for the repair of corporeal tears.

3. Procedure

1. The provider begins the procedure by preparing and anesthetizing the patient.
2. A Foley catheter is threaded through the urethra of the amputated penis and one end is passed into the patient’s bladder.
3. The provider repairs the urethra using sutures to create an anastomosis, joining the penile urethra to the bladder outlet circumferentially around the catheter.
4. Using microsurgical techniques, the provider sutures the penile vessels to their opposing structures in the pelvic area.
5. The provider reattaches the penile tissues to the remaining tissue at the site of amputation.
6. Any bleeding is controlled and the procedure is concluded.

4. Qualifying circumstances

CPT 54438 is used when a patient’s penis has been completely amputated or lost due to causes such as an avulsion or crush injury. This procedure is typically performed in cases of industrial accidents or self-mutilation by psychiatric patients. It is important to note that this code should not be used for the repair of incomplete penile amputation or for the repair of corporeal tears.

5. When to use CPT code 54438

CPT code 54438 should be used when a provider performs the complete replantation of a completely amputated penis, including the repair of the urethra. It is important to ensure that the procedure meets the specific criteria outlined in the code description. This code should not be used for incomplete penile amputation or for the repair of corporeal tears.

6. Documentation requirements

To support a claim for CPT code 54438, the provider must document the following information:

• Patient’s medical history and the reason for the replantation procedure
• Details of the procedure, including the repair of the urethra
• Date and duration of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 54438, it is important to ensure that the procedure meets the specific criteria outlined in the code description. This code should not be reported with other codes for incomplete penile amputation or for the repair of corporeal tears. It is important to follow the appropriate coding guidelines and modifiers when submitting the claim for reimbursement.

8. Historical information

CPT code 54438 was added to the Current Procedural Terminology system on January 1, 2016. Since its addition, there have been no updates or changes to the code.

9. Examples

1. A patient undergoes replantation of a completely amputated penis, including urethral repair, after an industrial accident.
2. A provider performs the complete replantation of a completely amputated penis, including the repair of the urethra, in a case of self-mutilation by a psychiatric patient.
3. After a crush injury, a patient undergoes the replantation of a completely amputated penis, including urethral repair.
4. A provider performs the complete replantation of a completely amputated penis, including the repair of the urethra, in a case of avulsion injury.
5. Following a sharp amputation, a patient undergoes the replantation of a completely amputated penis, including urethral repair.