Urology Coding Alert

Knowing when to use modifiers 52 and 22 is key to proper payment

The urologist clearly documents that he removed the patient's penile prosthesis and replaced it with another type of penile prosthesis. The procedure was straightforward, so your coding should be too, right? Not quite.

The problem: You won't find one code to represent the removal of one type of prosthesis and its replacement with another type. But don't fret. Our experts will give you the lowdown on how to properly code prosthesis exchanges.

Base Coding on Prosthesis Inserted

When a urologist removes one type of prosthesis and replaces it with a different type of prosthesis, you're left searching through 10 procedure codes representing penile prosthesis insertion and removal that cover a wide range of penile implant procedures.

To choose the proper code for the removal and replacement, you should follow one rule: Base your coding on what type of prosthesis you inserted, not on the type you removed, says Elizabeth Hollingshead, CPC, CMC, corporate billing/coding manager of Northwest Columbus Urology Inc. in Marysville, Ohio.

Why? You should choose the code for what your urologist inserted because the insertion portion of the procedure is the most effort- and time-consuming. You'll most likely choose one of the following codes:

• 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.

Example: During surgery, the urologist removes a semirigid noninflatable penile prosthesis and at the patient's request replaces this semirigid prosthesis with a multicomponent inflatable prosthesis. Code for the placement of the multicomponent inflatable prosthesis using 54405 (Insertion of multicomponent, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir) or 54410-52.

Append modifier 52 (Reduced services) to indicate that your urologist also removed a simpler semirigid noninflatable penile prosthesis.

"Because I used modifier 52, I would send documentation explaining a noninflatable or self-contained inflatable penile prosthesis was removed, not a multi-component inflatable penile prosthesis," says Martha Guyer, CPC, coding specialist for Piedmont Urological Associates in High Point, N.C.

Important: If the urologist is performing the removal and replacement of a multicomponent prosthesis through an infected surgical field, be sure that you use 54411, Hollingshead says. "This code includes the extra work involved in the debridement and irrigation that's needed," she adds.

Avoid the Temptation to Report 2 Codes

You may think that since the urologist is removing one type of prosthesis and inserting another one that you can report both a removal and an insertion code. Think again. When the physician performs two procedures, coding guidelines require that you use the code that encompasses both procedures, rather than two individual codes, if one is available.

"I would not report two codes in this situation because all the removal-only codes state, 'without replacement of prosthesis,' " Guyer adds.

How it works: A patient had a semirigid rod implanted two years ago. He decides to have the rod replaced with an updated, enhanced multiple-component prosthesis. Your urologist performs this procedure, removing the simple, noninflatable rod prosthesis and replacing it with a multi-component inflatable one.

You cannot report two separate codes to represent the removal of one type of prosthesis and the insertion of another -- that is, you shouldn't report 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 in the same surgical session.

Key: "The coder needs to be familiar with names of the prostheses and which ones are multicomponent and which are noninflatable or self-contained inflatable," Guyer says.

Append a Modifier to Tell the Rest of the Story

Some replacement scenarios will require more time and effort from your urologist than the procedure code represents. If the procedure is more extensive than the code describes, you should append modifier 22 (Increased procedural services) to the procedure code.

Example: Your urologist removes a multicomponent prosthesis and replaces it with a semirigid one. You should report the code for the removal and replacement of a semirigid prosthesis (54416) to reflect the type of prosthesis that the physician inserted. Then append modifier 22 to account for the additional work and time spent removing the pump and reservoir.

Remember: If the actual surgery is less than what the procedure code describes, you would attach modifier 52 as in the first example above. Another option would be to code only for the more complex insertion of a multi-component prosthesis (54405), and disregard the removal of the simpler semirigid prosthesis because this constitutes a relatively minor part of the whole procedure.