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The procedure described by CPT® Code 54437 involves the surgical repair of traumatic corporeal tear(s) that occur in the penis. This type of injury typically affects the corpora cavernosa and corpus spongiosum, which are critical components of the penile structure. These structures are encased in a robust layer of connective tissue known as the tunica albuginea, which plays a vital role in the mechanics of an erection by stretching and thinning. Traumatic corporeal injuries are most frequently the result of blunt force trauma, often occurring when the erect penile head strikes the pubic symphysis or perineum. Patients may experience a variety of symptoms, including a distinct “popping” sound at the time of injury, rapid detumescence (loss of erection), significant pain, swelling, and abnormal curvature of the penis. Although less common, corporeal tears can also occur in a flaccid penis due to sports injuries or other forms of trauma. The injury typically results in tearing of the tunica albuginea and/or the corpora cavernosa, leading to the formation of a hematoma within Buck’s fascia, a layer of tissue surrounding the erectile bodies. The surgical repair aims to restore the integrity of these structures, alleviate symptoms, and prevent complications associated with the injury.
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The procedure is indicated for the repair of traumatic corporeal tear(s) that may arise from various forms of blunt trauma to the penis. The following conditions and symptoms warrant this surgical intervention:
The surgical procedure for repairing traumatic corporeal tear(s) involves several critical steps to ensure proper healing and restoration of function. The following procedural steps are performed:
Post-procedure care is essential for optimal recovery following the repair of traumatic corporeal tear(s). Patients are typically monitored for any signs of complications, such as infection or excessive bleeding. Pain management is provided as needed, and patients may be advised to avoid sexual activity for a specified period to allow for proper healing. Follow-up appointments are crucial to assess the healing process and ensure that the repair is successful. Additional considerations may include the need for imaging studies if complications arise or if there are concerns about the integrity of the repair.
| Short Descr | REPAIR CORPOREAL TEAR | Medium Descr | REPAIR OF TRAUMATIC CORPOREAL TEAR(S) | Long Descr | Repair of traumatic corporeal tear(s) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AG | Primary physician | GC | This service has been performed in part by a resident under the direction of a teaching physician | SG | Ambulatory surgical center (asc) facility service |
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| 2016-01-01 | Added | Added |
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