Urology Coding Alert

Don’t miss your chance for extra reimbursement if complications arise.

When the urologist sees a male patient for concerns regarding erectile dysfunction, implantation of a penile device might be the final solution if other treatment approaches fail (such as use of medications or a vacuum erection system [L7900]). Accurate coding for the procedure will depend on collecting details such as the type of prosthesis used, the surgical approach, and more.

Base Insertion Code on Prosthesis Type

CPT^® offers several codes related to penile prosthesis insertion and removal. The insertion codes include:

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

Know the differences: Inserting a non-inflatable/semi-rigid prosthesis (code 54400) means that the penis will always be slightly rigid or firm. The penis can be bent away from the body for sexual activity and bent toward the body at other times.

An inflatable, or self-contained, prosthesis (code 54401) performs just as it sounds – it can be inflated to create an erection and deflated at other times. The multi-piece inflatable prosthesis (code 54405) creates the most natural erection because of its multiple parts, but also is the most extensive surgical procedure with the most potential risks.

“Often the choice of which prosthesis is implanted is purely a personal preference,” says Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook. “However, a patient must have good hand dexterity to satisfactorily use a multi-component prosthesis requiring hand inflation of the pump to produce the erection.”

Tip: Many multi-component implants have three pieces. If the urologist chooses to implant a two-piece prosthesis, you will still report 54405.

Report Removal Around Components and Complications

While most prosthesis insertions are a success, no surgical procedure is without potential complications. Patients sometimes need to have penile prostheses removed because of infection, early or late postoperative pain, scar tissue formation, mechanical implant failure, or other reasons.

If your urologist removes the prosthesis and does not replace it, you should report either 54406 (Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis) or 54415 (Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis), depending on the type of prosthesis removed.

“Removal of the prosthesis without replacement for the reasons discussed above may occur in a patient not wishing to continue with a penile prosthesis for which he was not completely satisfied or because of a severe infection requiring removal and long-term antibiotic treatment,” Ferragamo notes.

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

If the urologist removes the prosthesis and replaces it with another one, CPT^® offers several code choices for consideration:

• 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
• 54416 – Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session.

Note: To report reduced services because the urologist removed some components but not all, submit 54411 with modifier 52 (Reduced services).

Pay Attention to Different Components

Codes 54410, 54411, and 54416 represent scenarios when the urologist removes a prosthetic device and replaces it with the same type. Sometimes, however, two different types of prostheses are involved.

Example: The urologist removes a three-piece penile prosthesis and implants a single-component, non-inflatable prosthesis in its place during the same surgical encounter. You’ll report a combination code that most accurately reflects the services rendered. In this case, that probably means reporting 54416 with modifier 22 (Increased procedural service) to represent the additional work involved with removing the previously placed multi-component prosthesis.

Be cautious: Some payers will not reimburse for removal of a prosthesis or implant during the same operative session as placement of a new one. In that scenario, bill only for the type of prosthesis implanted and do not code for the prosthesis removal. In the above example, report only 54400 for insertion of the new prosthesis. Ferragamo adds that you may wish to check with the payer in question prior to surgery to verify how to submit the claim.

Change Codes When Complications Appear

Be prepared to include other services on your claim as appropriate if complications arise during surgery.

Example: The urologist schedules a patient for surgery to insert a non-inflatable, semi-rigid penile prosthesis. During surgery the urologist must terminate the procedure because he finds a urethral tear that needs repair.

Code it: Submit 54400 for the corporal dilation and rod insertion portion of the procedure. Append modifier 53 (Discontinued procedure for the well-being of the patient) because the full procedure was terminated due to the urethral injury.

Because the urologist needed to spend significant time and effort during the surgery to repair the urethral tear, this also becomes a billable service at the time of the terminated primary procedure. You should also report 53505 (Urethrorrhaphy, suture of urethral wound or injury; penile). If the claim is for a non-Medicare insurer, append modifier 51 (Multiple procedures) to the repair code to document that the urologist performed more than one procedure during the operative session.