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    OpenPayerBilling CodesRepair Procedures on the PenisCPT cpt-54316-hypospadias-second-stage-repair-skin-graft
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    CPT 54316: Hypospadias Repair, Second-Stage with Skin Graft

    Medicare pays $908 on average nationally for this procedure.

    CPT code 54316 describes a second-stage surgical repair of hypospadias performed typically six to twelve months after correction of penile curvature and the initial hypospadias procedure; the service includes diversion of urine via bladder catheterization and harvesting a skin graft from a non-penile donor site. This is a surgical procedure (hypospadias repair, second stage) most commonly performed in an operating room or ambulatory surgery center under regional or general anesthesia and involves urologic reconstructive techniques and tissue grafting.

    For related coverage guidance, see recent payer policy updates: Lymphedema - Surgical Treatment - Medical Policy, Breast Reduction (Mammoplasty) Surgery, Mastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays Mandates.

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    Clinical & Coding Specifications

    Clinical Context

    A typical patient is a pediatric male, often aged 6 months to 3 years, presenting for the second-stage surgical repair of hypospadias after initial correction of penile curvature (chordee) and first-stage reconstruction. The patient was staged previously with creation of a neourethral plate and/or placement of tissue grafts; this second-stage procedure reconstructs the urethra to the glans, harvests a skin graft from a non-penile donor site (commonly inner thigh or foreskin if available), and diverts urine via a catheter to protect the repair. The clinical workflow includes preoperative assessment (anesthesia evaluation, surgical consent, review of prior operative notes), intraoperative steps (general anesthesia, placement of urinary catheter, dissection and mobilization of tissue, placement of skin graft, tubularization or flap formation, hemostasis), and immediate postoperative care (monitoring in PACU, catheter care instructions, pain management, and scheduling follow-up visits at 1–2 weeks for wound check and catheter removal timing typically at 7–14 days). Typical site of service is an ambulatory surgery center or hospital operating room equipped for pediatric urologic surgery. Common perioperative considerations include anesthesia type, blood loss assessment, infection prophylaxis, and documentation of donor site and graft specifics.

    Related CPT Codes

    CPT CodeDescriptionRelationship to This Procedure
    54320Repair of hypospadias, second stage, with anticipated graft, closure of urethraOften used for similar second-stage hypospadias repairs; may be an alternative depending on exact technique and documentation.
    54150Repair of hypospadias; simple, single-stage repairRepresents a single-stage approach; contrasted with the staged repair represented by 54316.
    15734Muscle, myocutaneous, or fasciocutaneous flap with microvascular anastomosis (free flap)Used if complex grafting or flap coverage requiring advanced reconstructive technique is performed in conjunction.
    13160Secondary closure of surgical wound or dehiscence; scalp, arms, legs, hands, feet, or trunkMay be used for donor site management or secondary wound closure if separate from primary urologic repair.
    51702Placement of temporary indwelling catheter, simple (e.g., for diversion during procedure)Documents catheter insertion for urinary diversion when separately reportable.

    Related Modifiers

    13 rows

    ModifierDescriptionWhen to Use
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    23Modifier -23 (Unusual Anesthesia) is used on anesthesia service CPT codes when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia…- Use modifier -23 only on anesthesia CPT codes (00100–01999) when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia because of…
    26Modifier 26 (Professional Component) identifies and bills only the professional portion of a split service — the physician’s interpretation, report, and medical judgment — when the technical…- Use CPT Modifier -26 when you are billing only the professional component (PC) of a split‑bill eligible service—i.e., you performed the physician interpretation, medical judgment and prepared a…
    50Modifier –50 (Bilateral Procedure) is appended to a CPT code when an identical procedure is performed on paired anatomical structures during the same operative session. The AMA states to add…- Use modifier -50 when the same CPT surgical, diagnostic, or radiology procedure is performed on paired anatomical structures (both sides of the body) during the same operative/session by the same…
    51Modifier –51 (Multiple Procedures) is used when the same provider performs multiple procedures in the same session to identify secondary, non‑exempt procedures and indicate payment reduction logic…- Use modifier -51 when the same provider performs multiple distinct procedures during the same patient encounter: report the highest‑valued procedure first (no modifier) and append -51 to…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    62Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…
    63Modifier‑63 is appended to surgical CPT codes (20000–69990) when a procedure is performed on a neonate or infant weighing ≤ 4 kg (about 8.8 lbs). The AMA/AAPC definition specifies this use and notes…- Use modifier -63 only for surgical procedures in the CPT 20000–69990 series performed on a neonate or infant who weighs ≤ 4 kg at the time of the procedure; it indicates increased complexity due to…
    78CPT modifier -78 indicates an unplanned, related return to the operating or procedure room by the same provider during the global postoperative period. It is appended when treatment for a…- Use modifier -78 when an unplanned, related complication during the original procedure’s global postoperative period requires the patient to return to a formal operating or procedure room and the…

    Showing 1–10 of 13

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    2080P0206X
    207R00000X
    207L00000X
    207RP1001X
    2080B0002X
    103G00000X
    310400000X
    163WC0200X

    Related Payer Policy Updates

    Specialty: Plastic/Reconstructive Surgery1 / 2

    10 rows

    PolicyPayerEffective Date
    Lymphedema - Surgical Treatment - Medical PolicyHealth-New-England2027-02-01
    Breast Reduction (Mammoplasty) SurgeryKaiser Permanente2027-02-01
    Mastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays MandatesBlue Cross Blue Shield - Rhode Island2027-01-01
    Lipodystrophy Syndrome - HIV Associated - Medical PolicyHealth-New-England2026-12-01
    Abdominal Panniculectomy and Excision of Excessive Skin and Subcutaneous Tissue - Medical PolicyHealth-New-England2026-12-01
    Reduction MammaplastyBlue Cross Blue Shield - North Dakota2026-11-01
    Cosmetic and Reconstructive ProceduresAmbetter Georgia2026-11-01
    Surgical Treatment of Lipedema and Lymphedemahusky_health2026-11-01
    Rhinoplasty Medical Necessity and Site of ServicePremera Bluecross2026-10-14
    Reconstructive Breast Surgery/Mastopexy, and Management of Breast ImplantsBlue Cross Blue Shield - North Dakota2026-10-01

    Related Codes

    CPT-54300-CHORDEE-CORRECTION-URETHRAL-MOBILIZATION

    CPT 54300: Correction of Chordee (Penile Curvature)

    CPT-54304-CHORDEE-HYPOSPADIAS-REPAIR-STAGE-1

    CPT 54304: Chordee Correction or First-Stage Hypospadias Repair

    CPT-54308-HYPOSPADIAS-SECOND-STAGE-REPAIR-DISTAL-URETHRA

    CPT 54308: Second-Stage Hypospadias Repair with Distal Urethroplasty

    CPT-54312-HYPOSPADIAS-SECOND-STAGE-URETHROPLASTY

    CPT 54312: Second-Stage Hypospadias Repair with Distal Urethra >3 cm

    CPT-54318-HYPOSPADIAS-REPAIR-THIRD-STAGE-RELEASE

    CPT 54318: Third-Stage Hypospadias Repair, Release of Sutures

    CPT-54322-HYPOSPADIAS-MEATAL-ADVANCEMENT-V-FLAP-REPAIR

    CPT 54322: Hypospadias Repair with Meatal Advancement or V-Flap

    CPT-54324-HYPOSPADIAS-REPAIR-SINGLE-STAGE-URETHROPLASTY-LOCAL-FLAP

    CPT 54324: Hypospadias Repair with Local Skin Flap

    CPT-54326-HYPOSPADIAS-REPAIR-URETHROPLASTY-LOCAL-SKIN-FLAPS

    CPT 54326: Single-Stage Hypospadias Repair with Urethroplasty

    CPT-54328-SINGLE-STAGE-HYPOSPADIAS-REPAIR-CHORDEE-CORRECTION

    CPT 54328: Single‑Stage Hypospadias Repair with Chordee Correction

    CPT-54332-HYPOSPADIAS-REPAIR-CHORDEE-CORRECTION-URETHRAL-RECONSTRUCTION

    CPT 54332: Single-Stage Hypospadias Repair with Chordee Correction

    Showing 1–10 of 34

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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