Urology Coding Alert

Question: I performed a penile implant revision several weeks ago due to mechanical malfunction. The patient returned to the office with a severe infection. I admitted the patient to the hospital and performed the procedure to remove their implant. Since this is within the 90-day period of the original surgery, could you tell me how I should code the admission to the hospital and subsequent implant removal?

Delaware Subscriber

Answer: If the implant is removed and not subsequently replaced, your coding will be the same whether the penile implant is inflatable or semi-rigid. For the removal of an inflatable or semi-rigid penile implant without replacement, report 54415 (Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis).

Next, you’ve got to determine the correct modifier to append to 54415 to indicate that this is an unplanned return to the operating room (OR) of a related procedure during the original procedure’s global period. Scenarios involving postsurgical OR follow-ups that involve wound care or treatment of infections related to the original procedure meet the criteria for modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period).

Since the surgery was performed on the same day of admission, on top of the fact that a decision for surgery was made during the previous office visit, you should not report a separate charge for the hospital admission.