CPT Code 54450

spelster

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We have been using the cpt code 54450 when a newborn comes into the clinic after a curcumsicion and they have penile adhesions that the doctor says they take down by stretching. And that is pretty much all they say. Is this the correct code to use and is that enough documentation to be billing this code?

Thanks!
 

masequap

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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.
 
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