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The procedure described by CPT® Code 54163 refers to the surgical intervention known as the repair of incomplete circumcision. This procedure is indicated when there is an excessive amount of residual prepuce, commonly referred to as foreskin, that remains after a circumcision has already been performed. The presence of this excess foreskin can lead to complications or dissatisfaction with the initial circumcision outcome. To initiate the procedure, a general, regional, or local anesthetic is administered to ensure the patient experiences minimal discomfort during the operation. Once anesthesia is effective, the surgeon assesses the condition of the penis, specifically checking if the head, or glans, of the penis can be adequately exposed. If it is possible to expose the glans, the surgeon proceeds to excise the excess residual prepuce. However, in cases where the glans cannot be exposed due to the formation of adhesions—abnormal connections between the glans penis and the remaining foreskin—the surgeon first performs a lysis of these adhesions. This step is crucial as it allows for the safe exposure of the glans, after which the residual prepuce can be excised. This procedure aims to correct the incomplete circumcision and restore the normal anatomy of the penis.
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The procedure of repairing an incomplete circumcision is indicated under specific circumstances where the residual prepuce may cause functional or aesthetic concerns. The following conditions warrant this surgical intervention:
The procedure for repairing an incomplete circumcision involves several critical steps that ensure the effective removal of the residual prepuce. The following outlines the procedural steps:
After the completion of the repair of incomplete circumcision, post-procedure care is essential for optimal recovery. Patients are typically monitored for any immediate complications following the surgery. Instructions regarding wound care, signs of infection, and activity restrictions are provided to ensure proper healing. Patients may experience some swelling and discomfort, which can be managed with prescribed pain relief medications. Follow-up appointments are usually scheduled to assess the healing process and to ensure that the surgical site is recovering appropriately. It is important for patients to adhere to the post-operative care instructions to minimize the risk of complications and to promote a successful recovery.
| Short Descr | REPAIR OF CIRCUMCISION | Medium Descr | REPAIR INCOMPLETE CIRCUMCISION | Long Descr | Repair incomplete circumcision | 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) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 115 - Circumcision |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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). | 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. | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | 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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| 2002-01-01 | Added | First appearance in code book in 2002. |
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