Question: A patient was scheduled to receive a penile prosthesis. However, because of a urethral injury during surgery, the urologist only did a corporotomy on the left side with insertion of a malleable prosthesis. This temporary prosthesis will then be replaced with an inflatable prosthesis in about eight weeks, when the urethral injury heals. How should I code the initial surgery? Also, when things heal and the urologist replaces the prosthesis with the secondary inflatable prosthesis with reservoir and pump, can we bill for both 54400 and 54405-52?
RCI Subscriber
Answer: Since the urethral injury occurred as a result of the surgeon’s actions or the surgical procedure itself, you should report 54400 (Insertion of penile prosthesis; non-inflatable (semi-rigid)) with modifier 53 (Discontinued procedure) attached. The repair of the injury to the urethra is not separately payable using 53510 (Urethrorrhaphy, suture of urethral wound or injury; perineal). Because the surgery was discontinued due to the urethral trauma, modifier 53 is appropriate.
Helpful tip: Apply modifier 53 when a procedure is terminated post-anesthesia due to patient safety concerns. This informs the payer that the procedure was not completed, as the patient’s health was potentially endangered. On the other hand, use modifier 52 (Reduced services) for elective cancellations post-anesthesia due to the inability to achieve the intended result. This signifies that the service provided was significantly less than typically required for the code descriptor; for instance, when a procedure is unsuccessful or a bilateral procedure is only performed on one side.
On the other hand, if the injury occurred prior to the surgery and was completely unrelated, and the decision was still made to proceed with the trial of the rigid prosthesis after the repair, then 53510 and 54400-52 would be the best coding. Your payer would most likely reduce the allowed amount for 54400 based on your use of modifier 52 after asking for a copy of the surgical records.
Follow-up: When the time comes that your urologist performs the secondary surgery, your code choice will be determined by the specific actions performed by your urologist when substituting the prosthesis with an inflatable one equipped with a reservoir and pump. If they remove and replace the prosthesis, you’ll likely report 54416 (Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session). If they repair the components of a multi-component inflatable pump and connect the pump to the already-placed components, you’ll report 54408 (Repair of component(s) of a multi-component, inflatable penile prosthesis).
Lindsey Bush, BA, MA, CPC, Development Editor, AAPC