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The procedure described by CPT® Code 54115 involves the surgical removal of a foreign body from deep penile tissue, which may include items such as plastic implants. This procedure is typically indicated when a foreign object has been implanted in the penile area and requires surgical intervention for removal due to complications or patient discomfort. The patient is positioned supine, which means lying on their back, to facilitate access to the surgical site. Prior to the incision, the penis is meticulously prepared and draped to maintain a sterile environment, minimizing the risk of infection. The surgical approach involves making an incision along the shaft of the penis directly over the location of the foreign body. The incision is carefully extended down to the corpus cavernosum and/or corpus spongiosum, which are the erectile tissues of the penis, until the foreign object is clearly visualized. Surrounding tissue that may be devitalized or infected is dissected away to ensure complete removal of the foreign body. Following the extraction, the wound is irrigated with saline and/or an antibacterial solution to cleanse the area. A drain may be placed to facilitate fluid drainage, and the wound is then closed using simple sutures. After the procedure, a sterile dressing is applied to protect the surgical site, and both the dressing and drain are typically removed 2-3 days post-operation, allowing for proper healing and recovery.
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The procedure associated with CPT® Code 54115 is indicated for the removal of foreign bodies from deep penile tissue. This may include situations where a patient has a plastic implant or other foreign object that has become problematic. The indications for this procedure can include:
The procedure for the removal of a foreign body from deep penile tissue involves several critical steps, which are outlined as follows:
After the procedure, the patient is monitored for any immediate complications. The sterile dressing applied to the surgical site is intended to protect the area as it begins to heal. The drain, if placed, is typically removed along with the dressing 2-3 days post-operation. Patients are advised to follow any specific post-operative care instructions provided by their healthcare provider to ensure proper healing and to report any signs of infection or complications, such as increased pain, swelling, or discharge from the surgical site.
| Short Descr | TREATMENT OF PENIS LESION | Medium Descr | REMOVAL FOREIGN BODY DEEP PENILE TISSUE | Long Descr | Removal foreign body from deep penile tissue (eg, plastic implant) | 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) | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 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 | SG | Ambulatory surgical center (asc) facility service |
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| Pre-1990 | Added | Code added. |
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