2025 CPT code 54163
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Male Genital System Feed
Repair of incomplete circumcision.
Modifiers are applicable. Common modifiers include 22 (Increased Procedural Services), 51 (Multiple Procedures), 52 (Reduced Services), 53 (Discontinued Procedure), and others. The specific modifier used depends on the circumstances of the procedure.
Medical necessity should be established by documenting the patient's symptoms, functional limitations, and/or complications resulting from the incomplete circumcision. Examples include pain, difficulty with hygiene, recurrent infections, phimosis, or paraphimosis.
In simple words: This procedure fixes problems with a previous circumcision by removing any extra foreskin left behind.This can help with problems like painful erections or trouble peeing.
This procedure involves the removal of excessive residual foreskin remaining from a previous circumcision. This is typically done to address issues such as difficulty urinating or pain during erections. The procedure involves freeing adhesions between the residual foreskin and the glans penis, excising the foreskin, achieving hemostasis, suturing the incised skin bridge, and applying ointment and a dressing.
Example 1: A 5-year-old male presents with difficulty retracting his foreskin and recurrent infections. Upon examination, it is determined that his previous circumcision was incomplete, leaving excess foreskin. Procedure 54163 is performed to remove the residual foreskin., A 20-year-old male experiences pain during erections due to tight residual foreskin from a childhood circumcision. He undergoes procedure 54163 to excise the excess foreskin and alleviate the pain., An infant who had a circumcision shortly after birth develops penile adhesions and skin bridges, restricting normal foreskin movement. Code 54163 is used for the revision procedure, which includes lysis of adhesions.
Documentation should include details about the patient's prior circumcision, the current symptoms or issues related to the incomplete circumcision (e.g., pain, difficulty urinating, infections), a physical exam of the penis, and the details of the revision procedure performed, including lysis of adhesions if necessary.
- Specialties:Urology, Pediatric Urology, Pediatric Surgery
- Place of Service:Office, Ambulatory Surgical Center, Outpatient Hospital, Inpatient Hospital (if medically necessary for inpatient stay)