Does it seem to you like the original pump was only repositioned? The provider wants to bill 54410 but I'm thinking the original pump was not replaced? I'm just not 100% sure and I don't want to assign modifier -52 in error. Thanks!
POSTOPERATIVE DIAGNOSIS: Malfunctioning genitourinary penile prosthesis.
PROCEDURE PERFORMED: Removal of components of the nonfunctioning
Coloplast inflatable penile prosthesis, 22 cm
Coloplast Titan cylinders with 1 cm rear tip
extenders and replaced with new 22 cm
Coloplast Titan cylinders with 1 cm rear tip
extenders and a new reservoir 125 cc placed
through the left inguinal canal leaving the existing
reservoir behind the right inguinal canal.
ANESTHESIA: General.
DETAILS OF PROCEDURE: This gentleman had a history squamous cell carcinoma of
the rectum treated with surgery, chemotherapy and radiation therapy, now about 16 years ago. About five
years ago, he had an inflatable penile prosthesis placed and recently it went flat. He was referred here for
repair of same. Options were discussed. We felt that he was a suitable candidate for the
above-mentioned procedure. He received appropriate preoperative antibiotics in the holding area, was
taken to the operating room, given a general anesthetic. A timeout was taken for identification purposes.
Given a 10-minute shave prep and 10-minute scrub prep. His urethra and bladder were irrigated out with
antibiotic solution, and a Foley catheter was inserted. A transverse scrotal incision was made carried
down to the existing pump, which the tubing from which was followed to the entrance sites of both
corporal bodies. These were incised longitudinally. The previously placed cylinders and rear tips were
removed. The exit tubing from the pump heading toward the reservoir was followed high up into the
inguinal canal and then the tubing was cut. A pocket was then created behind the pubic bone on the left
side through the left inguinal canal through which 125 cc of reservoir was placed without difficulties and
inflated. The corporal bodies were irrigated out with antibiotic solution as if they were infected, but there
was no sign of any infection. The new 22 cm cylinders were inserted with 1 cm rear tip extenders and
good placement was noted. The corporotomies were oversewn with interrupted 2-0 Vicryl ligature. The
pump was pulled into the midline in the inferior most aspect for easy access postoperatively. A fluted face
drain was placed through a stab wound in the right hemiscrotum and the dartos was closed in a multitude
of interrupted layers. The skin was closed over subcuticularly. A Hypafix dressing was then placed.
POSTOPERATIVE DIAGNOSIS: Malfunctioning genitourinary penile prosthesis.
PROCEDURE PERFORMED: Removal of components of the nonfunctioning
Coloplast inflatable penile prosthesis, 22 cm
Coloplast Titan cylinders with 1 cm rear tip
extenders and replaced with new 22 cm
Coloplast Titan cylinders with 1 cm rear tip
extenders and a new reservoir 125 cc placed
through the left inguinal canal leaving the existing
reservoir behind the right inguinal canal.
ANESTHESIA: General.
DETAILS OF PROCEDURE: This gentleman had a history squamous cell carcinoma of
the rectum treated with surgery, chemotherapy and radiation therapy, now about 16 years ago. About five
years ago, he had an inflatable penile prosthesis placed and recently it went flat. He was referred here for
repair of same. Options were discussed. We felt that he was a suitable candidate for the
above-mentioned procedure. He received appropriate preoperative antibiotics in the holding area, was
taken to the operating room, given a general anesthetic. A timeout was taken for identification purposes.
Given a 10-minute shave prep and 10-minute scrub prep. His urethra and bladder were irrigated out with
antibiotic solution, and a Foley catheter was inserted. A transverse scrotal incision was made carried
down to the existing pump, which the tubing from which was followed to the entrance sites of both
corporal bodies. These were incised longitudinally. The previously placed cylinders and rear tips were
removed. The exit tubing from the pump heading toward the reservoir was followed high up into the
inguinal canal and then the tubing was cut. A pocket was then created behind the pubic bone on the left
side through the left inguinal canal through which 125 cc of reservoir was placed without difficulties and
inflated. The corporal bodies were irrigated out with antibiotic solution as if they were infected, but there
was no sign of any infection. The new 22 cm cylinders were inserted with 1 cm rear tip extenders and
good placement was noted. The corporotomies were oversewn with interrupted 2-0 Vicryl ligature. The
pump was pulled into the midline in the inferior most aspect for easy access postoperatively. A fluted face
drain was placed through a stab wound in the right hemiscrotum and the dartos was closed in a multitude
of interrupted layers. The skin was closed over subcuticularly. A Hypafix dressing was then placed.