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A biopsy of the penis is a medical procedure that involves the removal of tissue from the deeper structures of the penis for diagnostic purposes. This procedure is typically indicated when there is a suspicious mass or lesion that requires further investigation to determine its nature, such as the presence of cancer or other pathological conditions. In contrast to a simple biopsy, which involves the removal of superficial tissue, the procedure associated with CPT® Code 54105 entails a more invasive approach. The area to be biopsied is first disinfected to minimize the risk of infection, and a local anesthetic may be administered to ensure patient comfort during the procedure. However, in some cases, particularly when deeper structures are involved, a general anesthetic may be necessary. The surgeon makes an incision in the skin over the lesion and carefully dissects the overlying tissues to expose the suspicious mass. Once the mass is accessible, a tissue sample is obtained and sent to a laboratory for histological evaluation, which is reported separately. This detailed examination of the tissue sample is crucial for accurate diagnosis and subsequent treatment planning.
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Biopsy of the penis, as described by CPT® Code 54105, is indicated for the following conditions:
The procedure for a biopsy of the penis involves several critical steps to ensure accurate tissue sampling and patient safety.
After the biopsy procedure, patients may experience some discomfort or swelling at the site of the incision. It is important for healthcare providers to monitor the patient for any signs of infection or complications. Patients are typically advised on post-procedure care, which may include keeping the area clean and dry, avoiding strenuous activities, and following up with their healthcare provider for results and further management. The histological evaluation results will guide the next steps in treatment, depending on the findings.
| Short Descr | BIOPSY OF PENIS | Medium Descr | BIOPSY PENIS DEEP STRUCTURES | Long Descr | Biopsy of penis; deep structures | 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) | 1 - Statutory 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) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 2 | CCS Clinical Classification | 116 - Diagnostic 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. | 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.) | AG | Primary physician | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | 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 | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| Pre-1990 | Added | Code added. |
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