How To Use CPT Code 55180

CPT 55180 describes a complicated scrotoplasty procedure, which involves the reconstruction of the scrotum to repair birth defects or restore a damaged scrotum due to injury or disease. 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 55180?

CPT 55180 is a code used to describe a complicated scrotoplasty procedure. This procedure involves the reconstruction of the scrotum, which is the pouch that contains the testes or testicles. It is performed to repair birth defects or rebuild a scrotum that has been damaged due to injury or disease. In some cases, a scrotum may also be constructed from the labial tissue of a female patient during sex reassignment surgery.

2. Official Description

The official description of CPT code 55180 is: ‘Scrotoplasty; complicated.’

3. Procedure

1. During a complicated scrotoplasty procedure, the provider begins by making an incision in the scrotum.
2. They then remove any damaged or malformed tissue and fill in defects using skin flaps taken from adjacent scrotal skin.
3. The skin flaps are rotated into place with their vascular supply intact on a pedicle, or stalk.
4. The provider takes care to preserve the nerves and vessels of the testes.
5. After irrigating the area and checking for bleeding, all incisions are closed.

4. Qualifying circumstances

CPT 55180 is used for scrotoplasty procedures that are considered complicated. These procedures are performed to repair birth defects or reconstruct a damaged scrotum. The provider may use skin flaps from adjacent scrotal skin to fill in defects, ensuring that the vascular supply remains intact. It is important to preserve the nerves and vessels of the testes during the procedure.

5. When to use CPT code 55180

CPT code 55180 should be used when a provider performs a complicated scrotoplasty procedure. This code is appropriate when the scrotum requires reconstruction due to birth defects, injury, or disease. It should not be used for simple scrotoplasty procedures or other unrelated procedures.

6. Documentation requirements

To support a claim for CPT 55180, the provider must document the following information:

• Reason for the scrotoplasty procedure, such as birth defects, injury, or disease
• Details of the procedure, including the use of skin flaps and preservation of nerves and vessels
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 55180, ensure that the procedure meets the criteria for a complicated scrotoplasty. It is important to document the details of the procedure and any additional procedures or complications. CPT code 55180 should not be reported with other unrelated codes. If a testicular prosthesis is inserted during the same session, report it separately using the appropriate code.

8. Historical information

CPT 55180 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A provider performs a complicated scrotoplasty procedure to repair a birth defect in a patient’s scrotum.
2. During a complicated scrotoplasty, the provider reconstructs a damaged scrotum due to a traumatic injury.
3. A patient undergoes a complicated scrotoplasty procedure to restore their scrotum after it was affected by a disease.
4. In a sex reassignment surgery, the provider constructs a scrotum from the labial tissue of a female patient.
5. A provider performs a complicated scrotoplasty to repair a birth defect and improve the appearance and function of the scrotum.
6. During a complicated scrotoplasty, the provider uses skin flaps to fill in defects and reconstruct the scrotum.
7. A patient undergoes a complicated scrotoplasty procedure to address a congenital abnormality in their scrotum.
8. In a revision scrotoplasty, the provider repairs and improves a previously reconstructed scrotum.
9. A provider performs a complicated scrotoplasty to reconstruct a scrotum that was damaged due to a disease.
10. During a complicated scrotoplasty, the provider carefully preserves the nerves and vessels of the testes to maintain their function.