2025 CPT code 54162
Lysis or excision of penile post-circumcision adhesions.
Modifiers may be applicable to indicate specific circumstances, such as increased procedural services (22), multiple procedures (51), or distinct procedural service (59).
Medical necessity must be established. This may include pain, restricted foreskin movement, phimosis, paraphimosis, balanitis xerotica obliterans, or recurrent infections.
The physician is responsible for preparing the patient, administering anesthesia, performing the lysis/excision, controlling bleeding, suturing, and applying a dressing.
In simple words: This procedure removes scar tissue that has formed on the penis after a circumcision. The doctor will carefully separate the scar tissue, clean the area, stop any bleeding, and stitch the skin back together. This is usually done with tools, numbing medicine, and in a sterile environment.
This code describes a procedure where a provider breaks down (lyses) or removes (excises) adhesions that have formed on penile tissues after a circumcision. It involves retracting the foreskin, freeing adhesions between the foreskin and glans penis, incising skin bridges, removing excess tissue, applying antiseptic, controlling bleeding, and suturing the penile shaft skin to the remaining foreskin. This procedure typically requires instrumentation, anesthesia, and sterile conditions.
Example 1: A male infant experiences pain and restricted foreskin movement due to adhesions several months after circumcision. The pediatrician performs a lysis of adhesions under local anesthesia using instruments in a sterile setting., A young boy presents with difficulty retracting his foreskin due to significant post-circumcision adhesions and bridging. The physician performs an excision of the adhesions and reconstructs the area using sutures under general anesthesia in an operating room., An adult male who underwent circumcision as a child develops painful adhesions that restrict sexual function. The urologist performs a lysis of adhesions with instruments under regional block in an outpatient surgical center.
Documentation should include the medical necessity for the procedure (e.g., pain, restricted foreskin movement, infection), the type of anesthesia used, the instruments used, the extent of the adhesions, any complications, and the postoperative care instructions.
- Global Days: 10 days
- Specialties:Pediatrics, Urology, Family Medicine
- Place of Service:Office, Ambulatory Surgical Center, Outpatient Hospital, Inpatient Hospital