Code and documentation
CPT code 54450: Foreskin manipulation including lysis of preputial adhesions and stretching
Per the Coder's Desk Refernence this procedure is defined as: The physician treats adhesions between the uncircumcised foreskin and the head of the penis that prevent the retraction of the foreskin. Adhesions are broken by stretching the foreskin back over the head of the penis onto the shaft or by inserting a clamp between the foreskin and the head of the penis and spreading the jaws of the clamp.
According to the CMS State Operation's Manual (
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//som107ap_a_hospitals.pdf), the operative note should contain:
The operative report includes at least:
Name and hospital identification number of the patient;
Date and times of the surgery;
Name(s) of the surgeon(s) and assistants or other practitioners who performed surgical tasks (even when performing those tasks under supervision);
Pre-operative and post-operative diagnosis;
Name of the specific surgical procedure(s) performed;
Type of anesthesia administered;
Complications, if any;
A description of techniques, findings, and tissues removed or altered;
Surgeons or practitioners name(s) and a description of the specific significant surgical tasks that were conducted by practitioners other than the primary surgeon/practitioner (significant surgical procedures include: opening and closing, harvesting grafts, dissecting tissue, removing tissue, implanting devices, altering tissues); and
Prosthetic devices, grafts, tissues, transplants, or devices implanted, if any.
So it seems like you are using the correct CPT code for the procedure. Some of the requirements listed may not be applicable to the procedure.