Circumcision
5416154150wRVU: 1.85 — Circumcision using clamp or device with regional dorsal penile or ring block (neonatal/infant; 1.85 wRVU, 0-day global — Gomco, Mogen, Plastibell)54160wRVU: 2.47 — Circumcision, surgical excision, neonate <28 days (no device; 2.47 wRVU, 10-day global)54162wRVU: 3.24 — Lysis or excision of penile post-circumcision adhesions (3.24 wRVU, 10-day global; for skin bridges, adhesions requiring OR)54163wRVU: 3.24 — Repair of incomplete circumcision (3.24 wRVU, 10-day global; for re-excision of residual foreskin)54164wRVU: 2.75 — Frenulotomy of penis (2.75 wRVU, 10-day global; NCCI-bundled into 54150-54163 — cannot be separately billed at same session even with modifier -59)
[Phimosis / recurrent balanoposthitis / lichen sclerosus / patient preference]
Same
Circumcision, [sleeve resection / Gomco clamp / Mogen clamp / Plastibell device] technique
[Attending name], MD
[Resident/Fellow/PA name]
[General / IV sedation with MAC / dorsal penile nerve block / ring block]
Patient presents with [phimosis causing urinary obstruction / recurrent balanoposthitis / lichen sclerosus (BXO) / patient preference]. Conservative management with [topical steroid / barrier cream] [failed / not desired / not appropriate given extent of disease]. Risks including bleeding, hematoma, wound infection, altered glans sensation, cosmetic outcome, injury to glans or urethra, skin bridge formation, and need for revision discussed. Consent obtained.
[Phimotic / redundant / normal] foreskin with [scarring consistent with lichen sclerosus / inflammation / normal appearance] of the prepuce. Glans [fully visible after retraction / partially visible / not visible]. Frenulum [normal / short / adherent].
The patient was positioned supine and prepped and draped in sterile fashion. [A dorsal penile nerve block was performed using [X] mL of 0.5% bupivacaine without epinephrine, infiltrated at the 10 and 2 o'clock positions at the penile base just below the symphysis pubis, advancing through Scarpa's fascia and Buck's fascia. A ring block with an additional [X] mL was placed circumferentially in the subcutaneous tissue at the penile base.]
The foreskin was retracted. [In phimotic cases, a short dorsal slit was made to allow full retraction.] The coronal sulcus was identified. The outer skin marking was made on the penile shaft at the projected level of the coronal sulcus (with the foreskin in the reduced position, approximately at the corona). The inner mucosal marking was made on the inner preputial surface approximately [0.5-1] cm proximal to the corona, preserving a collar of inner mucosal tissue.
Using a sleeve resection technique, the outer prepuce was incised circumferentially along the outer marking. The inner prepuce was incised circumferentially along the inner marking. The intervening sleeve of foreskin was excised. The frenular artery (branch of the dorsal penile artery) was identified at the frenulum and ligated with 3-0 Vicryl; this is the highest-risk step for post-operative bleeding. Additional hemostasis was achieved with bipolar electrocautery. The mucosal and skin edges were re-approximated with interrupted 4-0 Vicryl Rapide [/ 4-0 chromic / 4-0 plain gut] sutures placed at four quadrants, followed by additional sutures for a circumferential closure.
A compressive non-circumferential dressing was applied. Patient tolerated the procedure well.
None
[Foreskin sent to pathology / Foreskin discarded]
Minimal
None
Patient was taken to PACU in stable condition. Discharged same day. Post-op instructions given (keep dressing 24-48 hours, warm soaks starting day 3, no intercourse/masturbation for 4-6 weeks, follow up in 2 weeks).
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Phimosis / recurrent balanoposthitis / lichen sclerosus / patient preference]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Circumcision, sleeve resection technique
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General / dorsal penile nerve block (0.5% bupivacaine WITHOUT epinephrine)
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [phimosis / recurrent balanoposthitis / lichen sclerosus / patient preference]. Conservative management [failed / not appropriate]. Risks of bleeding, hematoma, infection, altered sensation, cosmetic outcome, and glans/urethral injury discussed. Informed consent obtained.
FINDINGS: [Phimotic / redundant] foreskin with [scarring / inflammation / normal appearance]. Glans [visible / partially visible / not visible]. Frenulum [normal / short].
DESCRIPTION OF PROCEDURE:
Patient supine, prepped in sterile fashion. [DPNB: *** mL 0.5% bupivacaine WITHOUT epinephrine at 10 and 2 o'clock, subpubic, advancing through Buck's fascia; ring block *** mL subcutaneous.] Foreskin retracted. [Dorsal slit for phimosis.] Outer skin marking at projected coronal sulcus level on shaft. Inner mucosal marking 0.5-1 cm proximal to corona. Sleeve resection: outer prepuce incised circumferentially; inner prepuce incised circumferentially; foreskin sleeve excised. Frenular artery identified and ligated 3-0 Vicryl. Hemostasis bipolar electrocautery. Edges approximated interrupted 4-0 Vicryl Rapide at quadrants then circumferentially. Non-circumferential compressive dressing. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: [Foreskin to pathology / Discarded]
COMPLICATIONS: None
DRAINS: None
DISPOSITION: PACU, discharged same day. Follow up 2 weeks.
Signed: .ME, .MYDEGREE
.TODAYVariants
Neonatal clamp technique — Gomco/Mogen/Plastibell (CPT 54150)
CPT 54150 (1.85 wRVU, 0-day global). Gomco clamp: bell placed over glans, clamp assembled, crushing of foreskin for 5 minutes, excision. Mogen clamp: faster, slightly higher glans injury risk, no bell required. Plastibell: ring device left in place; foreskin necrotizes and falls off at 5-10 days; preferred by some pediatricians. All require regional block (DPNB or ring block) to qualify for 54150. 0-day global means same-day nursery visits are separately billable; no post-op bundling.
Dorsal slit technique (CPT 54000/54001)
For severe phimosis when circumcision is not feasible or not desired. Longitudinal dorsal incision releases the phimotic ring. CPT 54000 (newborn, 1.55 wRVU) or 54001 (except newborn, 2.18 wRVU). Bill as standalone only when no circumcision is performed — these codes are NCCI-bundled into 54150-54161 when done as part of circumcision.
Preputioplasty (foreskin-sparing)
Y-V plasty or dorsal slit with transverse closure for mild phimosis. Foreskin is preserved. No specific CPT — bill based on the procedure performed (dorsal slit = 54000/54001 if standalone; complicated repair = unlisted code with 54161 as benchmark). Document indication (desire to retain foreskin) and technique.
Lichen sclerosus (BXO)
Document extent of involvement — meatal involvement, corporal involvement, or urethral stricture requires additional procedures. Always send foreskin to pathology (ICD-10 L90.0). Margin status should be assessed by pathology. If meatal stenosis is present at time of surgery, meatotomy/meatoplasty may be performed concurrently; document separately.
Post-circumcision adhesion lysis (CPT 54162)
CPT 54162 (3.24 wRVU, 10-day global) for skin bridges or adhesions requiring OR correction. Office lysis of minor adhesions without anesthesia is bundled into established-patient E/M. Document the need for OR-level intervention (extent of adhesions, failure of office management, need for anesthesia).
Charting Tips
- Document indication specifically — affects insurance coverage and ICD-10. Phimosis (N47.1), paraphimosis (N47.2), recurrent balanoposthitis (N47.6), lichen sclerosus (L90.0). Cosmetic/elective adult circumcision is not covered by most payers; prior authorization required.
- Document technique — sleeve resection, Gomco clamp, Mogen clamp, or Plastibell. Technique determines code (54150 for clamp/device, 54160/54161 for surgical excision).
- Document nerve block agent and confirm no epinephrine. Epinephrine is absolutely contraindicated in penile blocks. Document: 'dorsal penile nerve block performed with 0.5% bupivacaine without epinephrine.'
- Document frenular management. If frenulum is short or tethering, frenuloplasty/frenulotomy may be needed. Note: 54164 (frenulotomy) is NCCI-bundled with all circumcision codes and cannot be separately billed — document it in the note but do not submit as a separate CPT.
- Send foreskin to pathology for: adults over 50, lichen sclerosus/BXO, abnormal gross appearance, chronic recurrent balanitis, or any concern for malignancy. Squamous cell carcinoma of the penis, erythroplasia of Queyrat, and Bowen disease can all be found in otherwise-routine circumcision specimens.
Billing Tips
- 54161 (circumcision, 28 days of age or older, 3.24 wRVU, 10-day global) is the standard operative code for children and adults undergoing circumcision in the OR under anesthesia. The distinguishing feature from neonatal codes is age 28 days or older.
- Neonatal circumcision splits by technique, not by setting. 54150 (clamp or other device with regional dorsal penile or ring block, 1.85 wRVU, 0-day global) is used for Gomco, Mogen, or Plastibell circumcisions with a regional block — regardless of location (nursery, clinic, or OR). 54160 (surgical excision, neonate <28 days, 2.47 wRVU, 10-day global) is for freehand surgical excision without a device. The split is technique-based, not setting-based.
- Global period differs by code. 54150 has a 0-day global (CMS Endoscopic/Minor classification); same-day post-procedure visits require modifier -25. 54160 and 54161 have a 10-day global; routine wound checks within 10 days are bundled.
- 54162 (lysis or excision of penile post-circumcision adhesions, 3.24 wRVU, 10-day global) covers revision for penile adhesions, skin bridges, or incomplete circumcision requiring OR-level correction. Distinct from 54163 (repair of incomplete circumcision, 3.24 wRVU) which covers re-excision of residual foreskin.
- 54164 (frenulotomy of penis, 2.75 wRVU, 10-day global) is NCCI-bundled into 54150-54163 with modifier indicator 0 — it cannot be unbundled even with modifier -59. Frenular takedown during circumcision is inherent to the procedure. Do not separately bill 54164 when performed at the same session as circumcision.
- Dorsal slit without circumcision: 54000 (slitting of prepuce, newborn, 1.55 wRVU) or 54001 (except newborn, 2.18 wRVU). Both are 10-day global, separate-procedure codes bundled into 54150-54161 when performed as part of circumcision. Bill 54000/54001 only when dorsal slit is the definitive and sole procedure performed.
- Adult circumcision: many payers consider it cosmetic without documented medical indication. Obtain prior authorization for elective cases and document the specific indication (phimosis N47.1, paraphimosis N47.2, recurrent balanoposthitis N47.6, lichen sclerosus L90.0, or recurrent balanitis XN60). Cosmetic motivation alone is non-covered.
General coding reference. Verify with your institution’s billing department before submitting claims.