The Male Genital System subsection (54000-55899) of the CPT manual is divided into anatomic subheadings (penis, testis, epididymis, tunica vaginalis, scrotum, vas deferens, spermatic cord, seminal vesicles, and prostate) . The category codes are divided according to procedure. The greatest number of category codes are under the subheading Penis because there are many repair codes in this subheading. The other subheadings are primarily for incision and excision, with only a few repair codes for the remaining subheadings as follows:

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• Introduction (54200-54250)

• Repair (54300-54440)

• Manipulation (54450)

Testis (54500-54699)

• Excision (54500-54535)

• Exploration (54550-54560)

• Repair (54600-54680)

• Laparoscopy* (54690-54699)

Epididymis (54700-54901)

• Incision (54700)

• Excision (54800-54861)

• Exploration (54865)

• Repair (54900-54901)

Tunica Vaginalis (55000-55060)

• Incision (55000)

• Excision (55040-55041)

• Repair (55060)

Scrotum (55100-55180)

• Incision (55100-55120)

• Excision (55150)

• Repair (55175-55180)

Vas Deferens (55200-55400)

• Incision (55200)

• Excision (55250)

• Introduction (55300)

• Repair (55400)

Spermatic Cord (55500-55559)

• Excision (55500-55540)

• Laparoscopy* (55550-55559)

Seminal Vesicles (55600-55680)

• Incision (55600-55605)

• Excision (55650-55680)

Prostate (55700-55899)

• Incision (55700-55725)

• Excision (55801-55865)

• Laparoscopy* (55866)

• Other Procedures (55870-55899)

Reproductive System Procedures (55920)

Intersex Surgery (55970-55980)

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Penis (54000-54450)

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Incision (54000-54015)

Incisions: Under the Incision category (54000-54015) of the subheading

Penis, there is an incision and drainage code (54015).

Recall that under the Integumentary System section there are incision

and drainage codes. The code from the Penis subheading is for a deep incision,

not just an abscess of the skin. For the deep abscess described in 54015, the area is anesthetized, the abscess is opened and cleaned, and often a drain is placed to maintain adequate drainage​.

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Destruction (54050-54065)

Under the Destruction category (54050-54065) of the subheading Penis there are also destruction codes for lesions of the penis. These lesion destruction codes are divided on the basis of whether the destruction is simple or extensive. Simple destruction is further divided according to the method of destruction (e.g., chemical, cryosurgery, laser). The code for extensive lesion destruction can be reported no matter which method was employed to accomplish the extensive destruction. 

(For destruction or excision of other lesions, see Integumentary System)

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Excision (54100-54164)

Excision codes (54100-54164) include codes to report biopsy of the penis (54100, 54105). Note that 54100 has a designation of “separate procedure,” which means that the code is reported when the biopsy was the only procedure performed during the operative session.

 

To accomplish the biopsy, the physician removes a portion of a lesion by excision of a small section of the lesion (scalpel or scissors) or by a punch biopsy. A punch biopsy is commonly used with skin lesions and is performed with an instrument that is pencil-shaped that removes a round disk of tissue.

 

The opening left by the punch may require simple closure (suture) depending on the size of the skin defect created by the biopsy. A more complex biopsy (54105) of the penis involves the deeper layers of the penis and may require layered closure, which is reported separately.​

 

Peyronie disease is a curvature of the penis that results from plaque formation on the cavernous sheaths of the penis. The plaque develops on the lower and upper side of the penis where the erectile tissue is located. Inflammation results and leads to the formation of scar tissue. Over time, this fibrous plaque bends the penis. In severe cases, the penis arches during erection, causing pain. Surgical correction of the curvature involves removal of the penile plaque (54110-54112). Grafting of the defect may be necessary, depending on the extent of the removal. Code 54110 reports the excision of penile plaque when no grafting is required and 54111/54112 report excision when grafting is required.

 

Penile amputation can occur as a result of trauma or as a surgical procedure for penile cancer. If the procedure is the removal of only the penis (partial or complete), report the service with 54120 or 54125. If the procedure includes removal of the inguinofemoral lymph nodes, report the service based on the extent of the removal (54130, 54135).

 

Circumcision codes 54150-54161 are divided based on whether the circumcision was accomplished by means of a clamp/other device or surgical excision and whether the procedure was performed on a neonate or non-neonate. A clamp is a device that is used to restrain the foreskin of the penis while the skin is trimmed. Report newborn circumcisions that utilize a clamp or other device with 54150. Surgical excision of the foreskin is a procedure in which a clamp or other device is not used, and the surgeon directly excises the skin from the penis. Once the skin has been removed, the incision is closed with sutures. Report the surgical excision without the use of a clamp or other device with 54160 (neonate) or 54161 (except neonate).

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Introduction: Introduction codes (54200-54250) report various injection procedures, irrigations, plethysmography, and other tests. An example would be an injection procedure for Peyronie disease in which steroids are injected into the fibrous tissue of the penis to decrease pain, deformity, and fibrous tissue size. There are two ways the fibrous tissue can be injected: the first way is to inject steroids directly into the area of the lump formed by the fibrous tissue (54200), and the second way is to expose the fibrous tissue through an incision and then inject steroids into the fibrous tissue (54205).

 

Priapism is a state of prolonged erection that can last from hours to days because of the inability of the blood to flow from the penis, which returns the penis to a flaccid state. The condition may be caused by medications used to treat impotence, such as sildenafil citrate (Viagra) or medical conditions, such as leukemia, multiple myeloma, or tumor infiltrate. If medical intervention is necessary, the surgeon introduces a large needle into the corpus cavernosum and aspirates blood, which is keeping the penis erect. The corpus cavernosum is then irrigated with a saline solution. The entire procedure is reported with 54220.

 

Repair: Repair category (54300-54440) codes are for various repairs made to the penis. The code descriptions often state the condition for which the procedure is being performed.

 

For example, 54304 is plastic repair for correction of chordee or a first-stage hypospadias repair, and 54380 is plastic repair for epispadias. Many other codes also indicate the stage of the procedure.

 

Many of the Repair codes refer to repair of chordee and hypospadias. Chordee is a condition in which the penis has a ventral (downward) curve and is a congenital deformity. Hypospadias is a congenital abnormality in which the urethral meatus (opening) is abnormally placed, usually along the ventral aspect (underside) of the shaft. Degrees of hypospadias are classified according to location: anterior, middle, or posterior. Hypospadias may lead to chordee. The farther from the glans penis the opening is, the greater the chordee. Read the code descriptions for Repair codes carefully as many of the descriptions have only slight differences.

 

Codes in the range 54400-54417 report insertion, repair, or removal of various types of penile prostheses. The codes are divided based on the type of service and often on the circumstances of the service. Erectile dysfunction (impotence) is a condition in which the penis does not become erect. Impotence may be caused by a variety of conditions, such as obesity, chronic illness, or as a result of medication. One surgical solution to impotence is insertion of a penile implant. There are various types of penile implants, but mainly there are two broad categories: non-inflatable (malleable or semi-rigid, 54400) and inflatable (54401). These implants are inserted deep within the penile tissue. If the implant is subsequently removed, the removal procedure is reported with 54406 (inflatable) or 54115 (non-inflatable). On occasion, removal and replacement are accomplished during the same operative session. Removal of a previously placed prosthesis with insertion of a new prosthesis during the same operative session is reported with 54410, 54411 (inflatable), or 54416/54417 (non-inflatable).

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Testis:

 

Excision: The Excision category (54500-54535) codes report services such as biopsy, excision, orchiectomy, and exploration of the testis. Biopsies may be percutaneous (54500) or incisional (54505). If an incisional biopsy of the testis is performed bilaterally, report modifier -50 with 54505. Extraparenchymal is defined as unrelated to the essential elements of an organ. Removal of an extraparenchymal lesion of the testis is reported with 54512. An incision is made on the scrotum, and the testicle is pulled out through the incision where the tunica vaginalis is opened and the lesion is removed. The testicle is returned to the scrotum and the area is sutured closed.

 

An orchiectomy is the removal of a testis. CPT codes 54520-54535 report orchiectomies based on if the procedure was simple/radical, unilateral/bilateral, with/without testicular prosthesis insertion, and the approach used to gain access to the site. Watch for codes that specify unilateral or bilateral. For example, a simple orchiectomy with or without testicular prosthesis insertion (54520) reports a unilateral procedure. When the procedure is bilateral, modifier -50 must be added to correctly report the procedure.

 

Exploration, Repair, and Laparoscopy: Undescended testis (cryptorchidism) is a congenital condition in which the testis(es) did not descend into the scrotal sac. The condition may be unilateral or bilateral. The testis(es) may remain in the abdominal, inguinal, or prescrotal areas or may move back and forth between areas. Often, undescended testis is associated with a hernia, and if this was the case, during the hernia repair procedure, the undescended testis is brought down into the scrotum and anchored with sutures (orchiopexy). An exploration may be necessary to locate the undescended testis(es), and the choice of codes (54550, 54560) is determined based on the approach used (inguinal/scrotal or abdominal) to gain access to the area. The exploration codes report a unilateral procedure, so if a bilateral procedure was performed, add modifier -50. During an exploration, when no more definitive procedure is performed, it is only reported as an exploration. If the testis was located during the exploration and the surgeon moved the testis into the scrotal sac, the procedure is no longer an exploration but a corrective procedure (orchiopexy). An orchiopexy is reported with codes from the Repair category or the Laparoscopy category, depending on the technique used.

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An orchiopexy in which the operative site is opened to the surgeon’s view is reported with 54640 or 54650, depending on whether the approach was inguinal or abdominal. If the orchiopexy is performed laparoscopically, report the procedure with 54692.

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The following testes code ranges are unilateral and require modifier -50 if the procedure was performed bilaterally:

 

 

54500-54535 Excision

54550-54560 Exploration

54640-54680 Repair

54690-54692 Laparoscopy

 

The third-party payer may require the use of -RT and/or -LT rather than modifier -50.

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Epididymis :  The epididymis is a narrow, coiled tube located on the top of the testes that connects the efferent ducts at the back of each testicle to the vas deferens. The epididymis is divided into the caput (head), corpus (body), and cauda (tail). The epididymis can become infected, inflamed, or obstructed. When an abscess or hematoma forms in the epididymis, the surgeon may incise and drain the area (54700). At times, the testis, scrotal space, and epididymis are the site of abscess or hematoma. When any or all of these areas are incised and drained, the service is reported with 54700. For example, if the surgeon incised and drained the scrotal space, the service is reported with 54700. Or, if the surgeon incised and drained the testis, scrotal space, and epididymis, the service is reported with 54700. The one code reports incision and drainage of each or all of the areas.

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Excision: The Excision category (54800-54861) of the Epididymis codes reports biopsy, exploration (with/without biopsy), lesion or spermatocele excision, and unilateral or bilateral removal. A spermatocele is a cyst that contains sperm, and during the excision of the cyst the epididymis may or may not be removed depending on the damage to the area caused by the presence of the cyst. Code 54840 reports the excision of a spermatocele with or without an epididymectomy.

 

Repair: Repair to the epididymis is an epididymovasostomy. During epididymovasostomy, the epididymis is connected to the vas deferens. The surgical procedure is reported with 54900 or 54901, depending if the procedure was unilateral or bilateral. An operating microscope is often used during this procedure and reported separately with 69990. The following epididymis codes or code ranges are unilateral and require modifier -50 if the procedure was performed bilaterally:

 

54700             Incision

54800-54840 Excision

54865             Exploration

 

The third-party payer may require the use of -RT and/or -LT rather than modifier -50.

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Tunica Vaginalis:

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incision and Excision: The tunica vaginalis is a serous sheath of the testis, which can be the site of a hydrocele (fluid collection). The physician may aspirate the fluid or inject a substance such as a sclerosing agent (55000) to help prevent further accumulation of fluid. Another method of management of a hydrocele is excision (unilateral, 55040 or bilateral, 55041), which may be accompanied by a hernia repair that is reported separately (49495-49501).

 

Repair: A Bottle type repair (55060) is a surgical procedure performed to remedy a hydrocele of the tunica vaginalis. An incision is made in the inguinal or scrotal area, and the hydrocele is drained and repositioned. A catheter may be left in place to ensure continued drainage of the area and to prevent further fluid accumulation.

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Scrotum:

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Incision: The scrotum is the sac that contains the testes. If a lesion of the skin of the scrotum is removed, assign codes from the Integumentary System to report the service. However, if the abscess is in the scrotal wall and requires drainage, report the procedure with 55100 (Drainage of scrotal wall abscess). If the abscess is of the epididymis, testis, and/or scrotal space, report the service with 54700 because the code reports procedures to any of the three areas.

 

Repair: Scrotoplasty (also known as oscheoplasty) is repair of a congenital abnormality or traumatic defect of the scrotum. Skin flaps may be utilized during a simple repair (55175) and in the more complex repair (55180) rotational pedicle grafts and/or free skin grafts may be used. Simple skin flaps are included in the scrotoplasty and not reported separately, but the more complex grafts are reported in addition to the scrotoplasty.

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Vas Deferens:

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Incision: The vas deferens is the tube that carries sperm from the testes to the ejaculatory duct and the urethra. A vasotomy (55200) is cutting into the vas deferens. Usually the procedure is performed to obtain a semen sample or to determine if there is obstruction. Code 55200 includes cannulization of the vas deferens. The code describes a unilateral or bilateral procedure, so there is no need to report modifier -50 with this code.

 

Excision: A vasectomy (55250) is a procedure in which a section of the vas deferens is removed for purposes of sterilization. A small incision is made on the scrotum, and the vas deferens is identified and brought out through the incision. A section of the vas deferens tube is cut and tied, stitched or sealed, and the vas deferens is returned to its natural position. The procedure includes a unilateral or bilateral procedure and postoperative semen examination(s). The semen is examined at intervals after sterilization to ensure the procedure was a success.

 

Introduction: A vasotomy (55300) may also be performed for a vasogram, seminal vesiculogram, or epididymogram in which colored dye is traced through the vas deferens to visualize any obstruction. The radiological supervision/interpretation is reported separately with 74440. When a vastomy is combined with a testis biopsy, report 54505-51.

 

Repair: A vasovasostomy or vasovasorrhaphy is a procedure to remove obstruction from the vas deferens or for a vasectomy reversal. Injection of dye is used during the procedure to identify the area of blockage. Once the area is identified, it is removed, and the ends of the vas deferens are anastomosed (reconnected end to end). Semen sampling may be conducted to ensure the removal of the blockage. Code 55400 reports a unilateral procedure; modifier -50 should be added to indicate a bilateral procedure. An operating microscope is often used during the procedure and is reported separately with 69990.

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Spermatic Cord:

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Excision and Laparoscopy. The spermatic cord is a collection of structures that suspends the testes in the scrotum as shown in the image/illustration below this content. The spermatic cord may be the site of formation of a hydrocele, lesion, or varicocele. Unilateral excision of a spermatic cord hydrocele is reported with 55500 with modifier -50 added to report a bilateral procedure. A varicocele is a mass of enlarged vessels that occurs when the valves that control blood flow in and out of the vessel become defective, and the blood is not able to circulate out of the vessel. The trapped blood causes the vessel to swell. Excision of a varicocele by means of a scrotal approach is reported with 55530, and an abdominal approach with 55535. A hernia repair may be performed during the same operative session, and with other procedures in this subsection have been reported separately. However, the single code 55540 reports both the varicocele excision and a hernia repair. If the varicocele is repaired using surgical laparoscopy, report the procedure with 55550.

 

The following spermatic cord code range is unilateral and requires modifier -50 if the procedure was performed bilaterally:

 

55500-55550 Spermatic cord (Excision and Laparoscopy categories)

 

The third-party payer may require the use of -RT and/or -LT rather than modifier -50.

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Seminal Vesicles:  

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The seminal vesicles are a pair of glands located posterior to (behind) the bladder. The glands provide the majority of the fluid that becomes semen and empties into the ejaculatory ducts and the urethra. Seminal vesicles codes are located in the 55600-55680 range.

 

 

Incision: A vesiculotomy is surgical cutting into the seminal vesicles. The approach can be by an incision into the lower abdomen or the perineum (between the anus and scrotum). Frequently, the procedure is performed to relieve pressure due to inflammation. There are two codes to report a vesiculotomy based on the extent of the dissection required to accomplish the procedure. If the procedure required simple dissection, report 55600, and if complicated dissection was required, report 55605. The codes are unilateral, so a bilateral procedure requires modifier -50.

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Excision: A vesiculectomy is the removal of one of the seminal vesicles. The procedure is performed to remove a tumor, calculus (stone), or other obstruction. The approach may be through the lower abdomen or perineum, but the choice of codes is the same (55650) because the code description indicates “vesiculectomy, any approach.” The code reports a unilateral procedure, so modifier -50 is required for a bilateral procedure.

 

The Mullerian ducts develop prenatally in females, and the Wolffian ducts degenerate. In males it is the opposite, the Wolffian ducts develop, and the Mullerian ducts degenerate. The Mullerian system develops into oviduct, uterus, and upper vagina. The Wolffian ducts develop into epididymis, vas deferens, and seminal vesicles. In some males a remnant of the Mullerian duct remains and a cyst may form at that site. The cyst may be excised using a lower abdominal or perineal approach and reported with 55680

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Prostate : 

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The most common conditions involving the prostate are inflammation (prostatitis), benign enlargement (BPH, benign prostatic hypertrophy), and cancer. Prostate cancer is the most common type of cancer in men.

 

Benign Prostatic Hyperplasia and Prostatectomy: The symptoms of BPH are urinary frequency, nocturia, urgency, decreased force of urine stream, and the feeling that the bladder has not completely emptied. These symptoms are a result of the excess prostate tissue pressing against the urethra and bladder. Treatment for BPH is based on the degree of prostate enlargement and severity of symptoms. Minimally invasive treatments include balloon dilation, prostatic stents, and thermal-based therapies. If these treatments are not successful, surgical intervention may be necessary, such as coagulation, transurethral resection, laser vaporization, or open surgical procedure.

 

BPH treatment and prostatectomy procedures are reported with codes from both the Urinary System and/or the Male Genital System.

 

Prostatic stents (52282 [permanent], 53855 [temporary]) are flexible metal mesh tubes designed to be inserted into the urethra at the level of the prostate and expanded after placement. The stent keeps the urethra open. Over time, the urothelial tissue grows over the stent and the stent becomes incorporated into the urethral wall. Transurethral microwave heat treatment (TUMT, 53850) is the use of microwaves that are sent through a catheter and introduced into the urethra to coagulate excess prostate tissue and allow the urethra to be less constricted. Transurethral needle ablation (TUNA, 53852) is a procedure that utilizes radiofrequency to create heat that is applied to the prostate to destroy excess prostate tissue. During this procedure the urethra is punctured to allow the needles to be placed directly into the prostate. The needles are insulated, so the urethra is not damaged when pierced. For some patients these less radical treatments are not effective or advisable. For example, for patients with renal insufficiency, recurrent gross hematuria, or bladder stones because of BPH, a surgical procedure is the recommended treatment option. Surgical therapies include transurethral prostate incision, electrovaporization, and laser ablation/coagulation. Let’s take a closer look at each of these surgical options:

 

Transurethral resection of the prostate (TURP, 52601, 52630) is the gold-standard of surgical procedures for removal of tumor or prostatic tissue. A special type of cystoscope is inserted through the urethra. The scope has lights, valves for controlling irrigation fluids, and an electrical loop to remove tissue and/or obstructions and cauterize blood vessels. Transurethral incision of the prostate (TUIP, 52450) is used when the prostate is only slightly enlarged. Two incisions are made in the prostate to relieve the pressure on the urethra without removing tissue.

 

When a laser is used to accomplish the prostatectomy, the choice of codes is first based on whether the procedure was a coagulation (52647) or vaporization (52648). Code 52648 includes with or without transurethral resection of the prostate

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L A S E R C O A G U L AT I O N ( 5 2 6 4 7 ) :

 

Transurethral ultrasound-guided laser induced prostatectomy (TULIP, non-contact) is a procedure in which a laser is used to coagulate prostate tissue. There is no direct visualization of the prostate using this method, and the penetration is not as deep as with other more commonly performed methods.

 

Visual laser of the prostate (VLAP, non-contact) is under the direct vision of the surgeon, but the laser fiber does not come in direct contact with the prostate. This method coagulates the tissue rather than vaporizing it. Once coagulated, the tissue dies and is sloughed off, which relieves the pressure.

 

Interstitial laser coagulation of prostate (ILCP, contact) uses several laser fibers that are placed directly into the prostate to coagulate the tissue. There is no direct visualization with the ILCP.

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L A S E R VA P O R I Z AT I O N ( 5 2 6 4 8 ):

 

Transurethral vaporization of the prostate (TUVP or TVP, contact) uses electrical current to vaporize tissue of the prostate by means of a ball that is rolled over the tissue. The ball contains a current that vaporizes the tissue. This procedure is a modification of a TURP.

 

L A S E R VA P O R I Z AT I O N W I T H / W I T H O U T R E S E C T I O N ( 5 2 6 4 8 ) :

 

Holmium laser enucleation of the prostate (HoLEP, contact), also known as transurethral holmium laser resection (THLR), is a procedure used to resect prostate tissue by means of a holmium laser fiber. There is less intraoperative bleeding with this procedure than with a TURP.

 

There are many different techniques used to remove the prostate (prostatectomy). Codes in the Excision category (55801-55865) represent open surgical procedures. Determination of the correct code to report a prostatectomy (removal of the prostate) is based first on the approach (perineal, suprapubic, or retropubic).

 

• Perineal approach is through the space between the rectum and the base of the scrotum and is used to gain access to a prostate that is located closer to the perineal area.

 

• Suprapubic approach is through the lower abdominal region, and it is used to gain access to the front (anterior) surface of the bladder. The access to the prostate is gained by an opening in the bladder neck.

 

• Retropubic approach is also through the lower abdominal region and is used to gain access to the front (anterior) of the prostate. Once the correct approach has been identified, the extent of the procedure will determine code selection. The term “subtotal” used in many of the code descriptions means anything less than the total removal of the prostate, and the term “radical” means total removal of the prostate.

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Codes 55812-55815 and 55842-55845 include code selection based on the lymph node biopsy/ removal performed. If lymph node biopsy (single or multiple) and limited removal of pelvic lymph node(s) was performed, report 55812 (perineal approach) or 55842 (retropubic approach).

 

If lymph nodes were removed bilaterally and include the external iliac, hypogastric and obturator nodes, report 55815 (perineal approach) or 55845 (retropubic approach). A laparoscopic retropubic prostatectomy (LRP, 55866) is a minimally invasive procedure that may be utilized instead of an open procedure. Robotic assisted prostatectomy (RAP) is a new instrumentation used with LRP and is designed to assist in the performance of some surgical tasks. Several small incisions are made through which robotic instrumentation is inserted. The surgeon operates the instrumentation from a console. The use of RAP necessitates an assistant during surgery. Surgeons who use a RAP system are extensively trained by the manufacturer of the system before using the system during surgery. The new robotic systems enhance the precision with which the procedure can be performed.

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Biopsy: Biopsy of the prostate may be performed with a needle, punch, or by incision. Report a prostate biopsy with 55700 (needle, punch), 55705 (incisional), or 55706 (transperineal, stereotactic). Do not report these codes during the same procedure. For example, if, during the same operative session, a needle or punch biopsy of the prostate (55700) is undertaken, and it is followed by an incisional biopsy (55705) either to supplement or to obtain adequate tissue, the appropriate CPT code to report is 55705, not both codes. Do not confuse a prostate biopsy with a fine needle aspiration (FNA). During an FNA, fluid is withdrawn for analysis and is reported with 10021 or 10022.

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A prostatotomy is an incision into the prostate. Codes 55720 (simple) and 55725 (complicated) describe prostatotomies performed to drain an abscess. The surgeon inserts a needle into the prostate via the perineum or through the rectum. Reporting of the procedure is based on if the procedure was simple or complicated. A complicated prostatotomy would document excess bleeding or other factors that increase time and effort necessary to complete the service.