Urology Coding Alert

Once you’ve answered the quiz questions on page 3, compare your answers with the ones provided below.

Answer 1: You’ll code for penile prosthesis insertion using one of three codes:

• 54400 (Insertion of penile prosthesis; non-inflatable (semi-rigid))
• 54401 (Insertion of penile prosthesis; inflatable (self-contained))
• 54405 (Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir)

Answer 2: A non-inflatable or semi-rigid prosthesis maintains a certain level of firmness in the penis at all times. It can be adjusted away from the body for sexual activity and towards the body when not in use. You’ll code for insertion of this kind of prosthesis with CPT^® code 54400.

A self-contained or inflatable prosthesis operates as its name suggests — it can be inflated by the patient for an erection and deflated when not required. You’ll use CPT® code 54401 to report the insertion procedure for this kind of device.

Lastly, the multi-component inflatable prosthesis offers the most lifelike erection due to its multiple components, but it involves the most complex surgical procedure and carries the highest risk of complications. The insertion procedure code for this kind of implant is CPT^® code 54405.

Answer 3: There may be instances where a urologist must extract a penile prosthesis due to infection, post-surgery discomfort, scar tissue development, mechanical failure, or because the patient no longer wishes to have the implant. For coding a penile prosthesis removal without a subsequent replacement, refer to the specific codes provided:

• 54406 (Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis)
• 54415 (Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis)

Don’t miss: You should check the medical documentation to see what type of prosthesis your urologist removed to choose the appropriate code between 54406 and 54415.

Answer 4: You have only one option if the urologist performs a prosthesis repair: 54408 (Repair of component(s) of a multi-component, inflatable penile prosthesis).

Answer 5: If your urologist removes and replaces a penile implant, you will look to the following codes:

• 54410 (Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session)
• 54411 (Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue). Note: If your urologist removes some of the prosthesis components but not all of them, you should report code 54411 with modifier 52 (Reduced services) appended.
• 54416 (Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session)
• 54417 (Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue)

Remember: “When your urologist removes one type of prosthesis and replaces it with another type of prosthesis, always bill for the type of prosthesis that was newly implanted,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at State University of New York in Stony Brook, New York.

Mind these modifiers: When your urologist removes a multiple component prosthesis and replaces it with a non-inflatable semi-rigid prosthesis, report 54416 and append modifier 22 (Increased procedural services) to indicate the extra work they performed to remove the multiple component prosthesis. “If your urologist removes a semi-rigid prosthesis and replaces it with a multiple-component prosthesis, you’ll bill 54411 and append modifier 52 [Reduced services] to indicate the reduced work for the removal of the semi-rigid prosthesis,” Ferragamo adds.

“Be mindful that adding a modifier to the claim will trigger a manual review of the claim. Make sure that the documentation supports the work performed during the procedure. This applies to both modifiers 22 and 52. Make sure the extra time or reduced time is documented and the circumstances for the changes in the procedure performed are included in the surgical operative note. The clarification in the documentation will assist the reviewer in determining the payment for the claim,” says Stephanie Storck, CPC, CPMA, CUC, CCS-P, ACS-UR, longtime urology coding expert and consultant in Glen Burnie, Maryland.

You may also come across instances where your urologist faces a complication during the insertion of a penile prosthesis. For instance, if a non-inflatable, semi-rigid penile prosthesis insertion is planned but must be halted due to the discovery of a urethral tear requiring repair, you should use code 54400 with the addition of modifier 53 (Discontinued procedure). This modifier indicates that the procedure was discontinued for the patient’s well-being due to the unexpected urethral injury.