Urology Coding Alert

Question: Our surgeon revised a malfunctioning inflatable penile prosthesis. Our Blue Cross carrier gave us an authorization number for the procedure but then denied the claim, stating that the diagnosis was not correct for this procedure. We billed 54408 linked to 996.30. What other code should I use?

Virginia Subscriber

Answer: ICD-9 code 996.30 (Mechanical complication of genitourinary device, implant and graft; unspecified device, implant and graft) may not be specific enough for your carrier in this case. The word "unspecified" in the description of 996.30 suggests that your doctor did not specify the type of prosthesis that malfunctioned. But in this case, the doctor did specify the device - an inflatable penile prosthesis. The problem is that that particular device is not classified in the ICD-9 codes.

Remember: "Unspecified" and "not elsewhere classified" mean very different things in the world of ICD-9 coding. Report ICD-9 code 996.39 (... other). A code with "other" or "not elsewhere classified" in the description tells the carrier that you have specific information, but there is no specific ICD-9 code for it - in this case, the type of penile prosthesis.

And your carrier is probably looking for a diagnosis of organic impotence, which the patient almost certainly has. Report 607.84 (Other specified disorders of penis; impotence of organic origin) as the primary diagnosis, and report the malfunction, 996.39, as the secondary diagnosis. Link 54408 (Repair of component[s] of a multi-component, inflatable penile prosthesis) to the primary diagnosis, 607.84.