Urology Coding Alert

Question: Does CPT^® include a code for removal of only an IPP reservoir? Or is my best option to code a complete removal? My urologist has selected diagnosis code T83.498A for the encounter.

Washington Subscriber

Answer: The current CPT^® manual does not include a code that accurately describes the removal and replacement of a single component of a three-piece inflatable penile prosthesis. Your best alternative is to report either 54410 (Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session) or 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). Append modifier 52 (Reduced services) and include documentation explaining which part of the described service the urologist completed.

More specific ICD-10 diagnoses would include T83.490A, other mechanical complications of implanted penile prosthesis, other mechanical complication of penile prothesis reservoir, initial encounter, for CPT code 54410 or T83.61XA, infection and inflammatory reaction due to implanted penile prosthesis, infection and inflammatory reaction due to penile prosthesis reservoir, initial encounter, for CPT^® code 54411.