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The procedure described by CPT® Code 54000 involves the slitting of the prepuce, which is the fold of skin that covers the glans penis in uncircumcised males. This procedure is specifically indicated for newborns who may have a condition known as phimosis, where the prepuce is too tight to be retracted. The physician performs a dorsal or lateral incision to alleviate this tightness, allowing for better hygiene and potential prevention of future complications. The dorsal slit refers to an incision made on the upper side of the prepuce, while a lateral slit involves incisions made on the sides. This procedure is categorized as a separate procedure, meaning it is distinct from other surgical interventions and is performed solely for the purpose of addressing the tightness of the prepuce in newborns. It is important to note that CPT® Code 54000 is specifically designated for use when the procedure is performed on a newborn, while a different code, CPT® Code 54001, is used for similar procedures performed on patients who are not newborns.
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The slitting of the prepuce, as described by CPT® Code 54000, is indicated for specific conditions related to the prepuce in newborns. The primary indication for this procedure is:
The procedure for slitting the prepuce involves several key steps that ensure the effective treatment of the condition. These steps include:
After the slitting of the prepuce, the newborn may require some monitoring to ensure there are no immediate complications such as excessive bleeding or signs of infection. Parents or caregivers are typically provided with instructions on how to care for the area, including keeping it clean and monitoring for any unusual symptoms. It is important to follow up with the healthcare provider if there are concerns about healing or if the infant exhibits signs of discomfort. Recovery is generally quick, and most newborns can resume normal activities shortly after the procedure.
| Short Descr | SLITTING OF PREPUCE | Medium Descr | SLITTING PREPUCE DORSAL/LATERAL SPX NEWBORN | Long Descr | Slitting of prepuce, dorsal or lateral (separate procedure); newborn | Status Code | Active Code | Global Days | 010 - Minor Procedure | 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) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | 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) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 117 - Other non-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). | 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. |
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| Pre-1990 | Added | Code added. |
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