2025 CPT code 54161
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Male Genital System Feed
Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age.
Modifiers may be applicable. Modifier 52 (Reduced services) may be used if the procedure is discontinued. Modifier 22 (Increased Procedural Services) should be appended if the service was substantially more difficult than usual.
Medical necessity for this procedure must be established. Acceptable reasons can include phimosis, recurrent balanitis, or other medical conditions where circumcision is deemed the appropriate treatment. Religious or cultural reasons may also be considered.
The physician is responsible for preparing the surgical site, administering anesthesia, performing the circumcision using a non-clamp/non-device technique, and applying post-operative care including dressings. They must also manage any complications.
In simple words: This procedure involves the surgical removal of the foreskin in males older than one month. The doctor uses a specific cutting technique that doesn't involve clamps or other devices. After the foreskin is removed, the area is cleaned and covered with a protective dressing.
Surgical removal of the foreskin (prepuce) in patients older than 28 days, using a technique other than a clamp, other devices, or a dorsal slit. The procedure may involve freeing the prepuce from the glans, applying forceps, and excising the skin. Alternatively, a double circumferential incision with a connecting longitudinal incision may be used. The frenulum may be included in the excision or cut separately. Post-operative care includes applying petroleum jelly and gauze wrapping.
Example 1: A 6-month-old male presents for circumcision due to recurrent balanitis. The procedure is performed using a surgical excision technique without a clamp or device., A 35-year-old male with phimosis undergoes circumcision using a surgical excision technique without a clamp or device to alleviate the condition., A 12-year-old male undergoes circumcision for religious reasons. The procedure is performed using a surgical excision technique without a clamp or device.
Documentation should include the patient's age, indication for the procedure (e.g., phimosis, balanitis, religious reasons, patient preference), type of anesthesia used, surgical technique employed, any complications encountered, and post-operative instructions.
- Global Days: 0
- Specialties:Urology, Pediatrics, Family Medicine
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center, Inpatient Hospital (if performed during initial newborn hospital stay)