Could someone help me with getting a for hair tourniquet of penis CPT code? The code that my provider used is 54115; which I do not agree with. See op note for details. I was wondering for this patient that I would use an unlisted procedure code.
This is a 7-year-old child with developmental delay known to the pediatric surgery service for gastrostomy tube placement in the past. He presented to his pediatrician this morning with a very swollen penis and she noted that there was a hair tourniquet around the glans of the penis. After consulting with me, he was sent to the ER at Greenville Memorial Hospital and I evaluated him, confirming the diagnosis. Because of his developmental delay and extreme agitation, I did not feel I could get an adequate evaluation and moreover remove the hair so we decided taken the operating room for mask sedation. The patient is taken to the operating room on an emergent basis for the above procedure following a discussion with the family of the intended procedure and its attendant risks which include but are not limited to infection, bleeding, injury to normal structures, need for additional operation.Details of procedure: The patient was identified and placed in the supine position on the operating table. Adequate anesthesia was induced. Timeout was performed and all present were in agreement. The perineum was prepped and draped in sterile fashion and a penile block was placed. The glans was very engorged but we are able to identify the hair and after untwisting this blood flow was restored adequately to the penis. The meatus had been obstructed by the hair and after removing the hair, I passed a 10 French Foley catheter to ensure patency; this passed easily. The catheter was removed and minimal blood loss was noted around the glans. There was no evidence of any necrosis. The procedure was well tolerated, and there were no complications.