2025 CPT code 54100
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Male Genital System Surgery Feed
Biopsy of the penis; superficial lesion (separate procedure).
Modifiers may be applicable depending on the circumstances of the procedure (e.g., 22 Increased Procedural Services, 51 Multiple Procedures, 59 Distinct Procedural Service, etc.).Refer to current CPT guidelines for modifier application rules.
Medical necessity for a penile biopsy is established when there is a clinical indication of a suspicious lesion that requires histopathological examination to guide treatment.Examples include lesions with atypical features (size, color, texture), persistent lesions not responding to conservative treatment, or lesions raising concerns of malignancy. The procedure must be documented as medically necessary by the physician and supported by the clinical findings.
The physician is responsible for all aspects of the procedure, including patient preparation, anesthesia administration (if applicable), tissue excision, and wound closure. Pathological examination of the excised tissue is the responsibility of a pathologist.
In simple words: The doctor takes a small sample of tissue from a surface-level growth or sore on the penis to find out what it is.
This CPT code 54100 represents the surgical procedure involving the removal of a tissue sample from a superficial lesion on the penis for diagnostic purposes.The procedure typically involves prepping and anesthetizing the area, then excising a small portion of the superficial lesion using a scalpel or punch biopsy instrument.Wound closure with sutures may be necessary depending on the size and location of the lesion. This code is specifically for superficial lesions; deeper lesions require code 54105.
Example 1: A 55-year-old male presents with a small, suspicious wart-like lesion on the glans penis.An incisional biopsy is performed using a scalpel, and the sample is sent for pathological examination. The lesion is superficial., A 30-year-old male presents with a persistent, slightly raised, reddish lesion on the penile shaft. A punch biopsy is performed, and the tissue sample is sent to pathology. The lesion is superficial., A 70-year-old male presents with a suspicious ulcerated lesion on the foreskin. An excisional biopsy is performed removing the entire lesion, and the specimen is sent to the pathology lab for analysis.The lesion is superficial.
* Complete patient history and physical examination notes documenting the presence of the lesion.* Detailed description of the lesion's location, size, and characteristics.* Documentation of the type of biopsy performed (incisional, excisional, or punch).* Note the size and depth of tissue removed.* Documentation of local anesthesia used (if any), and the method of hemostasis.* Photographic documentation (before and after procedure) of the lesion.* Pathology report with diagnosis.* Operative note detailing the procedure.
** Always confirm the appropriate code selection based on the depth of the lesion and the type of biopsy performed.Accurate documentation is crucial for appropriate reimbursement.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- RVU: Information not available in source data.Consult the most current Medicare Physician Fee Schedule for RVU values.
- Global Days : Information not provided.Global period will depend on payer and other factors.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule : Information not available in source data.
- Specialties:Urology, Dermatology
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgery Center