How To Use CPT Code 54450

CPT 54450 describes the procedure of foreskin manipulation, including the lysis of preputial adhesions and stretching. 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 54450?

CPT 54450 is used to describe a procedure in which a healthcare provider manipulates and stretches the foreskin of the penis to break down adhesions. This procedure is performed to treat phimosis, a condition in which the foreskin is not retracted from the head or glans of the penis. The provider may perform lysis of adhesions between the uncircumcised foreskin and the head of the penis or remove adhesions between the remaining foreskin and glans penis in a circumcised male.

2. Official Description

The official description of CPT code 54450 is: ‘Foreskin manipulation including lysis of preputial adhesions and stretching.’

3. Procedure

1. The healthcare provider prepares the patient and ensures appropriate anesthesia.
2. The provider manually pulls back the foreskin over the head and along the shaft of the penis to gently break up adhesions.
3. In an uncircumcised male, the provider may stretch the foreskin by inserting a clamp or a ring between the foreskin and glans penis and then spreading the clamp open to gently break the foreskin away safely.

4. Qualifying circumstances

CPT 54450 is performed on patients with phimosis, a condition characterized by the inability to retract the foreskin. The procedure is appropriate for both uncircumcised and circumcised males. The provider must manually break down adhesions between the foreskin and the head of the penis or remove adhesions between the remaining foreskin and glans penis.

5. When to use CPT code 54450

CPT code 54450 should be used when a healthcare provider performs foreskin manipulation, including the lysis of preputial adhesions and stretching. It is important to note that this code should not be used for routine circumcision procedures or other unrelated procedures.

6. Documentation requirements

To support a claim for CPT 54450, the healthcare provider must document the following information:

• Patient’s diagnosis of phimosis
• Details of the procedure performed, including the manipulation of the foreskin and lysis of adhesions
• Any additional procedures or services provided during the same encounter
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 54450, ensure that the procedure meets the specific requirements outlined in the code description. It is important to use the appropriate diagnosis code for phimosis and any additional services provided during the same encounter. If the procedure involves the use of instruments and general anesthesia, a different code may be more appropriate. It is crucial to review the documentation and guidelines to accurately report the procedure.

8. Historical information

CPT 54450 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 healthcare provider performs foreskin manipulation, including the lysis of preputial adhesions and stretching, to treat phimosis in an uncircumcised male patient.
2. A provider manually breaks down adhesions between the remaining foreskin and glans penis in a circumcised male patient with phimosis.
3. A healthcare provider uses a clamp to stretch the foreskin and safely break it away in an uncircumcised male patient with phimosis.
4. A provider performs foreskin manipulation to treat phimosis in an adult male patient.
5. A healthcare provider performs foreskin manipulation on a pediatric patient with phimosis, using appropriate anesthesia and techniques.
6. A provider performs foreskin manipulation on a patient with recurrent phimosis after a previous circumcision.
7. A healthcare provider performs foreskin manipulation on a patient with phimosis, providing relief from pain and difficulty with urination.
8. A provider performs foreskin manipulation on a patient with phimosis, improving their ability to maintain proper hygiene.
9. A healthcare provider performs foreskin manipulation on a patient with phimosis, preventing the need for a more invasive procedure such as circumcision.
10. A provider performs foreskin manipulation on a patient with phimosis, ensuring their comfort and well-being.