Urology Coding Alert

Question: My urologist states that a patient was scheduled for a penile prosthesis. However, due to a urethral injury during surgery, they only did corporotomy on the left side and insertion of a malleable prosthesis. This prosthesis will be replaced with inflatable prosthesis in six to eight weeks when urethral injury heals. How should I report the initial surgery? Then, when things heal and the urologist replaces the prosthesis with an inflatable prosthesis with reservoir and the pump, can we bill both 54400 and 54405-52?

Florida Subscriber

Answer: If the urethral injury was iatrogenic (caused by the surgeon) and happened during the surgery, 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). Since the surgery was discontinued due to the urethral trauma, modifier 53 is appropriate.

Pointer: Use modifier 53 when your provider aborts a procedure (after anesthesia is given) due to the safety of the patient. You are telling the payer that the doctor could not complete the procedure because the patient’s health and well-being were at risk. In contrast, you’ll use modifier 52 (Reduced services) for elective cancellation (after anesthesia is given) due to the inability to complete the service to the originally intended outcome. You are indicating a service was significantly less than usually required to fit the code descriptor, such as when a procedure fails or a bilateral procedure is performed on just one side.

Caveat: If the injury happened prior to the surgery and is 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 will reduce the allowed amount for 54400 based on your use of modifier 52, likely after asking to review the surgical records.

Next: When the time comes that your urologist performs the complete surgery, replacing the prosthesis with an inflatable prosthesis with reservoir and the pump, your coding will depend on what your urologist actually does. 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 components of a multi-component inflatable pump and connect the pump to the already placed components, you’ll instead report 54408 (Repair of component(s) of a multi-component, inflatable penile prosthesis).