How To Use CPT Code 54406

CPT 54406 describes the removal of all components of a multi-component, inflatable penile prosthesis without replacement of the prosthesis. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 54406?

CPT 54406 can be used to describe the removal of all components of a multi-component, inflatable penile prosthesis without replacing the prosthesis. This code is used when the provider removes the previously placed inflatable synthetic material, pump, cylinders, and reservoir from the patient’s penis. It is important to note that this procedure does not involve the replacement of the prosthesis.

2. Official Description

The official description of CPT code 54406 is: ‘Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An incision is made over the previous site of the penile prosthesis insertion near the pubic area or at the penile base.
3. The provider removes the previously placed inflatable synthetic material, cylinders from the corpora cavernosa, reservoir from the deep pubic bone area, and pump from the scrotum.
4. The tissues are closed with sutures, and the previously placed catheter is removed.

4. Qualifying circumstances

CPT 54406 is performed when a patient requires the removal of all components of a multi-component, inflatable penile prosthesis without replacing the prosthesis. This procedure is typically done for patients who no longer require or desire the penile prosthesis. It is important to note that this code should not be used if the prosthesis is being replaced.

5. When to use CPT code 54406

CPT code 54406 should be used when the provider performs the complete removal of all components of a multi-component, inflatable penile prosthesis without replacing the prosthesis. It is important to ensure that the prosthesis is not being replaced during the procedure. If the prosthesis is being replaced, a different CPT code should be used.

6. Documentation requirements

To support a claim for CPT 54406, the provider must document the following information:

• Reason for the removal of the penile prosthesis
• Details of the procedure, including the incision site and the removal of each component
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 54406, ensure that the procedure involves the complete removal of all components of a multi-component, inflatable penile prosthesis without replacing the prosthesis. This code should not be reported if the prosthesis is being replaced. It is important to follow any additional guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 54406 was added to the Current Procedural Terminology system on January 1, 2002. There have been no updates to the code since its addition.

9. Examples

1. A patient undergoes the removal of all components of a multi-component, inflatable penile prosthesis without replacing the prosthesis.
2. A provider performs the complete removal of a penile prosthesis, including the synthetic material, cylinders, reservoir, and pump.
3. A patient no longer requires the penile prosthesis and undergoes the removal of all components without replacement.
4. A provider removes the previously placed penile prosthesis, closes the tissues, and removes the catheter.
5. A patient decides to have the penile prosthesis removed and undergoes the complete removal procedure.
6. A provider performs the removal of all components of a penile prosthesis without replacing it for a patient who no longer desires the prosthesis.
7. A patient experiences complications with the penile prosthesis and undergoes the complete removal procedure.
8. A provider removes the previously placed penile prosthesis due to infection and ensures that no components are replaced.
9. A patient undergoes the removal of all components of a penile prosthesis without replacement for personal reasons.
10. A provider performs the complete removal of a penile prosthesis without replacing it for a patient who no longer requires the prosthesis.