Urology Coding Alert

Question: A patient presented with an infected non-inflatable penile prosthesis. We removed the old prosthesis and replaced the infected prosthesis with a multi-component inflatable one. I coded 54416 for the removal and 54405 for the replacement. Our carrier paid for the replacement but not the removal. Should I appeal?

Kansas Subscriber Answer: No. When you remove one type of prosthesis and replace it with a prosthesis of a different type, base your coding on the type of prosthesis you inserted, not on the type you removed. What confuses coders is that the descriptions of the procedures imply that you are removing a particular type of prosthesis and replacing it with the same type.

For example, 54416 (Removal and replacement of non-inflatable [semi-rigid] or inflatable [self-contained] penile prosthesis at the same operative session) sounds as if the doctor is inserting the same sort of prosthesis that he removed. But the type he inserts is the only one that is relevant when you code the procedure.

So in the example you mention, you really have two choices for proper coding.

Option 1: You can report 54405 (Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir), but you should not submit code 54416 in addition to 54405.

Option 2: Report 54410-52 (Removal and replacement of all components of a multi-component, inflatable penile prosthesis at the same operative session; reduced services). Modifier -52 indicates removal of a less complicated semi-rigid prosthesis. If the urologist also irrigates and debrides infected tissue, consider 54411 (Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue) and append -52 as above.