Circumcision

CPT 54161
Approach Open
Add-on / Variant CPTs
  • 54150 — Newborn circumcision (clamp device)
  • 54160 — Circumcision, surgical excision (neonate)
  • 54163 — Repair incomplete circumcision
Preoperative Diagnosis:

Phimosis / recurrent balanitis / penile hygiene / patient request

Postoperative Diagnosis:

Same

Procedure Performed:

Circumcision, sleeve resection technique

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General / local with IV sedation / dorsal penile nerve block
Patient in supine position.

Indications:

Patient presents with [phimosis with urinary obstruction / recurrent balanoposthitis / lichen sclerosus / patient preference]. Conservative management with topical steroid [failed / not desired]. Risks of bleeding, infection, altered sensation, cosmetic outcome, and injury to glans discussed. Consent obtained.

Findings:

[Phimotic / redundant] foreskin with [scarring / inflammation / normal appearance] of the prepuce. Glans [normal / partially visible / not visible]. Frenulum [normal / short / adherent].

Description of Procedure:

The patient was taken to the operating room, placed in supine position, and prepped and draped in sterile fashion. [A dorsal penile nerve block was performed using 0.5% bupivacaine without epinephrine, total [X] mL, infiltrated at the 10 and 2 o'clock positions at the base of the penis.]
A marking was made around the penis at the level of the coronal sulcus, approximately 1 cm from the glans, and a second marking made on the inner prepuce at the same distance from the corona. The foreskin was retracted as much as possible. [If phimotic, a dorsal slit was made to allow retraction.]
Using a sleeve resection technique, the outer prepuce was incised circumferentially along the marked line. The inner prepuce was incised similarly. The intervening foreskin was excised. Frenular vessels were identified and ligated with 3-0 Vicryl suture. Hemostasis achieved with bipolar electrocautery. The skin edges were re-approximated with interrupted 4-0 chromic sutures placed at four quadrants, followed by additional interrupted sutures as needed for a circumferential closure.
A compressive dressing was applied. Patient tolerated the procedure well.

Complications:

None

Specimens:

[Foreskin sent to pathology / Discarded]

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

Patient was taken to PACU in stable condition. Discharged same day.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: [Phimosis / recurrent balanitis / 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

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [phimosis with urinary obstruction / recurrent balanoposthitis / lichen sclerosus / patient preference]. Conservative management with topical steroid [failed / not desired]. Risks of bleeding, infection, altered sensation, and cosmetic outcome were discussed. Informed consent obtained.

FINDINGS: [Phimotic / redundant] foreskin with [scarring / inflammation] of prepuce. Glans [partially visible / not visible]. Frenulum [normal / short].

DESCRIPTION OF PROCEDURE:
Patient placed supine and prepped in sterile fashion. [Dorsal penile nerve block performed with 0.5% bupivacaine without epinephrine, *** mL, at 10 and 2 o'clock at penile base.] Circumferential markings made at the coronal sulcus approximately 1 cm from the glans, and on the inner prepuce at equal distance. [Dorsal slit made to allow retraction in phimotic foreskin.] Sleeve resection technique: outer prepuce incised circumferentially; inner prepuce incised similarly; intervening foreskin excised. Frenular vessels identified and ligated with 3-0 Vicryl. Hemostasis with bipolar electrocautery. Skin edges re-approximated with interrupted 4-0 chromic sutures placed at four quadrants then circumferentially. Compressive dressing applied. Patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: [Foreskin to pathology / Discarded]
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient taken to PACU in stable condition. Discharged same day.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Dorsal slit technique

For severe phimosis. Document dorsal incision length and subsequent trimming of redundant tissue.

Preputioplasty

Foreskin-preserving technique for mild phimosis. Document Y-V or dorsal slit with transverse closure.

Lichen sclerosus

Document extent of involvement, whether biopsy sent for pathology, and margin status. May require wider excision.

Charting Tips
  • Document indication clearly, as it affects coding (54150 vs 54161) and insurance coverage
  • State technique: sleeve resection, Gomco clamp, Plastibell, or freehand
  • Note frenular management (frenuloplasty if short frenulum)
  • Send specimen if lichen sclerosus, recurrent infections, or abnormal appearance suspected
  • Document nerve block technique and agent if performed
Billing Tips
  • 54161 (circumcision age 28 days or older, 3.24 wRVU) is the standard adult/pediatric operative code. Performed in an OR under general or regional anesthesia.
  • 54160 (neonatal circumcision, 2.47 wRVU) is for newborns under 28 days old; 54150 (with regional block only, 1.85 wRVU) is for newborns circumcised in the nursery with local nerve block.
  • Global period is 10 days (minor). Routine post-op wound checks within 10 days are bundled.
  • Phimosis (N47.1) vs paraphimosis (N47.2) vs recurrent balanoposthitis (N47.6): document the indication accurately, as payer medical necessity policies often require specific diagnoses for adult circumcision.
  • Dorsal slit (54000) or preputial adhesion lysis performed as a standalone without full circumcision has its own code. Do not bill separately if completed as part of circumcision.
  • Some payers consider adult circumcision cosmetic unless medically indicated. Obtain prior authorization and document recurrent infections, phimosis, or dermatologic condition requiring circumcision.
  • Frenuloplasty (if performed concurrently) is separately billable with modifier -59 when documented as a separate procedure with its own distinct indication.