2025 CPT code 54105

Biopsy of the penis involving deep structures.

Follow current CPT coding guidelines for surgical procedures. Accurate documentation is critical to ensure proper code selection.

Modifiers 22 (increased procedural service), 51 (multiple procedures), 58 (staged or related procedure), and others may be applicable depending on the circumstances.

Medical necessity is established when there is clinical suspicion of a penile lesion requiring histopathological examination for diagnosis and treatment planning. This may be based on clinical presentation, physical examination findings, or imaging studies.

The urologist or surgeon is responsible for performing the biopsy, including prepping the patient, administering anesthesia (local usually, but may require general if a simultaneous partial/total penectomy is performed), performing the biopsy using appropriate technique, and closing the incision.A pathologist interprets the biopsy results.

IMPORTANT Consider modifier 58 (staged or related procedure) if additional procedures are performed within the global period.Code 54100 may be used for superficial lesions.

In simple words: This code describes a procedure where a doctor takes a small sample of tissue from a deeper area of the penis to test for disease. The doctor uses a special tool to remove the sample, then stitches the area closed. The sample is sent to a lab to be checked.

This CPT code 54105 signifies a biopsy procedure targeting deep-seated lesions on the penis.The procedure involves removing a tissue sample from deeper layers, potentially including muscle, nerve, or vascular structures, unlike superficial biopsies.The technique may involve a deep punch biopsy or an incisional biopsy with dissection to access deeper tissue. The incision is subsequently closed with sutures. The tissue sample is then sent to a pathology lab for diagnosis.

Example 1: A patient presents with a palpable nodule on the penile shaft, suspicious for malignancy.A deep biopsy is performed to obtain tissue for histopathological examination to confirm or rule out cancer., A patient has a persistent, deep-seated lesion on the penis that has not responded to conservative treatment. A deep biopsy is taken to determine the etiology of the lesion and guide further management., Following a prior penile procedure (e.g., circumcision), a deep lesion is identified. A deep biopsy is done to rule out complications or recurrence.

Detailed patient history, physical examination notes specifying the location and characteristics of the lesion, operative report detailing the surgical technique (punch biopsy or incisional biopsy), pathology report with histological findings, and any relevant imaging studies (e.g., ultrasound).

** The depth of the biopsy is crucial for code selection.Superficial biopsies would utilize code 54100.Accurate documentation of the surgical technique and pathology findings is essential for proper reimbursement.

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