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The CPT® Code 54440 refers to a plastic operation of the penis specifically performed for injury, commonly known as phalloplasty. This complex surgical procedure is typically executed in multiple stages to reconstruct the penis following trauma or congenital anomalies. The initial stage of the procedure involves the meticulous harvesting of tissue from a donor site, which is most frequently the musculocutaneous latissimus dorsi (MLD) muscle. This harvested tissue is then fashioned into a neo-phallus, which is subsequently attached to the genital area. The surgical process begins with a skin incision that is extended down to the deep fascia, allowing the surgeon to create a plane between the latissimus dorsi and the serratus cutaneous muscles. During this stage, the flap of tissue is carefully divided and lifted to reveal the neurovascular pedicle, which is crucial for maintaining blood supply to the neo-phallus. The procedure requires the preservation of a small strip of muscle to ensure adequate vascularization. The dissection continues proximally to the axillary vessels, where the thoracodorsal nerve and its accompanying blood supply are identified and isolated. The neo-phallus is constructed while still attached to its blood supply, ensuring viability. In parallel, a second surgical team prepares the recipient site in the groin area, which involves making an inguinal incision to access and mobilize critical vascular structures such as the superficial femoral artery and saphenous vein. A Y-incision is created over the pubis, facilitating the connection between the inguinal site and the neo-phallus. The transfer of the neo-phallus from the chest to the pubis is executed using microsurgical techniques, establishing anastomoses between the arteries and veins to ensure proper blood flow. Following the successful implantation of the neo-phallus, additional stages may include urethroplasty and penile prosthesis insertion, which are separately reportable procedures. The urethroplasty can be performed concurrently with the initial phalloplasty stage if a buccal mucosa graft is utilized, or it may be conducted later once the neo-phallus has stabilized. The insertion of penile implants typically occurs 3 to 6 months after a successful urethroplasty, completing the reconstruction process.
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The procedure described by CPT® Code 54440 is indicated for patients who have sustained injuries to the penis, which may result from trauma, congenital defects, or other medical conditions that necessitate reconstruction. The following conditions may warrant the performance of this surgical intervention:
The procedure for CPT® Code 54440 involves several detailed steps, each critical to the successful reconstruction of the penis. The following outlines the procedural steps:
Post-procedure care following the plastic operation of the penis for injury includes monitoring for complications such as infection, hematoma, or issues related to the vascular supply of the neo-phallus. Patients are typically advised to follow specific postoperative instructions regarding wound care, activity restrictions, and signs of complications to watch for. Follow-up appointments are essential to assess the viability of the neo-phallus and to plan for subsequent stages of reconstruction, including urethroplasty and penile prosthesis insertion. The recovery period may vary based on individual patient factors and the complexity of the surgical procedure performed.
| Short Descr | REPAIR OF PENIS | Medium Descr | PLASTIC OPERATION PENIS INJURY | Long Descr | Plastic operation of penis for injury | Status Code | Carriers Price the 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 | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 118 - Other OR therapeutic procedures, male genital |
| 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). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 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.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | KX | Requirements specified in the medical policy have been met |
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| 2011-01-01 | Changed | Medium description changed. |
| Pre-1990 | Added | Code added. |
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