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The procedure described by CPT® Code 54015 refers to the incision and drainage of the penis, specifically targeting deep infections. This surgical intervention is typically performed when there is an accumulation of pus or fluid within the penile tissues, which may arise from various conditions such as abscesses or infections. The procedure begins with the patient lying supine, ensuring comfort and accessibility for the surgeon. An antiseptic solution is applied to the penis to minimize the risk of infection during the procedure. Local anesthetic is then infiltrated into the area to provide pain relief, allowing the surgeon to perform the incision without causing discomfort to the patient. The incision is made through the skin and extends down to the corpus cavernosum and/or the corpus spongiosum, which are the erectile tissues of the penis. This careful approach ensures that the infected area is adequately accessed, allowing for the drainage of pus or fluid. Following the drainage, any infected or devitalized tissue is debrided, which involves the removal of unhealthy tissue to promote healing. The wound is then thoroughly cleaned and irrigated with saline and/or an antibacterial solution to further reduce the risk of infection. A drain is placed to facilitate ongoing drainage of any residual fluid, and the wound is closed using simple sutures. Finally, a sterile dressing is applied to protect the area post-procedure, with instructions for the dressing and drain to be removed 2-3 days later, ensuring proper healing and monitoring for any complications.
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The procedure described by CPT® Code 54015 is indicated for the management of deep infections of the penis. These infections may present with symptoms such as:
The procedure for incision and drainage of the penis involves several critical steps to ensure effective treatment of the infection.
After the procedure, the patient is typically monitored for any immediate complications. The dressing and drain are scheduled to be removed 2-3 days later, allowing for adequate drainage and observation of the healing process. Patients may be advised on signs of infection or complications to watch for, such as increased redness, swelling, or discharge from the incision site. Follow-up appointments may be necessary to assess healing and ensure that the infection has resolved completely.
| Short Descr | DRAIN PENIS LESION | Medium Descr | I&D PENIS DEEP | Long Descr | Incision and drainage of penis, deep | 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) | 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). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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. | 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.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| Pre-1990 | Added | Code added. |
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