Advanced Search

Urology Coding Alert

Achieve Surefire Penile Prosthesis Reimbursement With This Handy Rule

Published on Tue Jul 01, 2003

When it comes to penile prosthesis codes, you won't find any to represent the removal of one type of prosthesis and its replacement with another type modifiers    -52 and -22 may be just what you need to get paid for your urologist's unusual removal-and-replacement procedures.

 CPT includes 10 penile prosthesis insertion and removal codes that cover a wide range of penile implant procedures, but they forgot one: a code to represent the removal of one type of prosthesis and the replacement with another type.

 For example, a patient presents for the removal of an infected noninflatable penile prosthesis, and after the removal procedure the urologist replaces the infected prosthesis with a multicomponent inflatable one. But there is no code to represent this procedure, says Judy Pate, CPC, coding specialist for the department of urology at Louisiana State University in Shreveport.

 When you remove one type of prosthesis and replace it with a prosthesis of a different type, there is a rule of thumb: Base your coding on what type of prosthesis you inserted, not on the type you removed. The following CPT codes are available:
 
  • 54410 Removal and replacement of all component(s) of a multicomponent   inflatable penile prosthesis at the same operative session
     
  • 54411 Removal and replacement of all components of a multicomponent   inflatable penile prosthesis through an infected field at the same operative session,   including irrigation and debridement of infected tissue
     
  • &54416 Removal and replacement of noninflatable (semirigid) or inflatable   (self-contained) penile prosthesis at the same operative session
     
  • &54417 Removal and replacement of noninflatable (semirigid) or inflatable   (self-contained) penile prosthesis through an infected field at the same operative   session, including irrigation and debridement of infected tissue
      
     As a general rule, you choose the code for what was inserted because the insertion portion of the procedure is the most effort- and time-consuming, says John J. Mulcahy, MD, MS, PhD, FACS, professor of urology at Indiana University School of Medicine in Indianapolis.

     Let's say a urologist removes a multicomponent prosthesis and replaces it with a semirigid one. You should report the code for the removal and replacement of a semi-rigid prosthesis to reflect the type of prosthesis that was inserted, then you should append modifier -22 (Unusual procedural services) to account for the additional work and time spent removing the pump and reservoir: 54416-22, Mulcahy instructs coders. "You are putting in the simple [prosthesis] but removing extra parts that take about 25 percent more time," which warrants the use of modifier -22 with the proper documentation, he adds.

     On the other hand, suppose a patient has a semirigid rod implanted by one urologist and one year later he decides to have the rod replaced with an updated, enhanced multiple-component prosthesis by another urologist. Rods work, Mulcahy says, but they don't give any flaccidity. When the urologist performs this procedure and removes a simple, noninflatable rod prosthesis and replaces it with a multicomponent inflatable one, you may have more than one coding option.

     Option 1: Because the removal procedure was less complicated than the replacement procedure, you can report the removal-and-replacement code for what was implanted (a multicomponent inflatable) and append modifier -52 (Reduced services): 54410-52.

     Option 2: You can simply report the code for the insertion of the multicomponent inflatable prosthesis. Mulcahy says that putting in a new three-piece multiple-component prosthesis takes about the same amount of time and surgical effort as taking out a simple rod and putting in a new three-piece prosthesis. If you use this coding method, you would simply report the insertion code, 54405 (Insertion of multicomponent, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir).

     Don't use separate codes to represent the removal of one type of prosthesis and the insertion of another, that is, coding 54415 (Removal of noninflatable [semirigid] or inflatable [self-contained] penile prosthesis, without replacement of prosthesis) for the removal of an inflatable self-contained prosthesis and 54405 for the insertion of a multicomponent prosthesis performed in the same surgical session.

     "When performing two procedures, CPT rules tell us to use a CPT code, if available, that encompasses both procedures rather than two individual codes," says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York at Stony Brook. Other common examples of multiple procedures included in one CPT code are cystoscopy (52000) and urethral dilation (53600), both of which are components of code 52281 (Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female).

    • Adhere to These Documentation Rules 

     Anytime you append a modifier to a procedure to increase your reimbursement, carriers become sticklers for documentation and modifier -22 always draws carrier scrutiny and will require a paper submission.

     When you append modifier -22 to a procedure code, be sure to:
     
  •  submit a paper claim
     
  •  include a copy of the operative report identifying diagnoses, pre-existing conditions, intraoperative problems and abnormalities found, etc., that played a role in the extra time/effort to perform the procedure
     
  •  include a statement from the physician indicating the patient's name, HIC, the procedure date, the requested percent increase for the fee and the circumstances (there is no limit on the increased fee requested, but most carriers will reimburse an increase of 25 to 33 percent)
     
  •  make sure you have made a case for the use of modifier -22, including a comparison of what was done to what is typically done.

     (See "Think You've Made Your Case for Modifier     -22? Not if You Haven't Done These 5 Things" in the enclosed issue of Urology Coding Alert Extra for more information on how to properly submit claims for unusual procedural services.)

    • Other Articles in this issue of

    Urology Coding Alert

    View All