Need some help coding a penile prosthesis removal with implantation of a different kind of prosthesis, see partial note below.
"I made the midline scrotal incision, and then traced his pump and corpora. There was a large, thick collection of old blood, it looked like a thick hematoma, I did not see pus at this point, but a large amount of currant jelly appearing hematoma, around the reservoir, pump, and cylinders which I took out.
I then did my 7 step Mulcahy salvage, irrigating with betadine, hydrogen peroxide, ancef/gent, and then in reverse order as well.
Next, I inserted a 23cm 11mm girth semirigid coloplast genesis implant."
I am confused as to whether I would code it as a removal and replacement of a semi rigid prosthesis, 54416, or as 54406 and 54400, coding separately the removal and replacement since they are two different types of prosthesis. Or would I code it as a removal and replacement through an infected field?
"I made the midline scrotal incision, and then traced his pump and corpora. There was a large, thick collection of old blood, it looked like a thick hematoma, I did not see pus at this point, but a large amount of currant jelly appearing hematoma, around the reservoir, pump, and cylinders which I took out.
I then did my 7 step Mulcahy salvage, irrigating with betadine, hydrogen peroxide, ancef/gent, and then in reverse order as well.
Next, I inserted a 23cm 11mm girth semirigid coloplast genesis implant."
I am confused as to whether I would code it as a removal and replacement of a semi rigid prosthesis, 54416, or as 54406 and 54400, coding separately the removal and replacement since they are two different types of prosthesis. Or would I code it as a removal and replacement through an infected field?