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The CPT® Code 54411 refers to the surgical procedure involving the removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field during the same operative session. This procedure is specifically indicated when there is an infection present, necessitating not only the replacement of the prosthetic device but also the irrigation and debridement of any infected tissue. The process begins with the insertion of a catheter transurethrally, followed by a midline incision in the lower abdomen, which allows access to the underlying structures. Surgeons identify the dorsal venous complex and the corporal bodies, carefully exploring the incision until they locate the tubing connected to the reservoir. The procedure requires meticulous dissection to free the reservoir, pump, and cylinders from their respective anatomical locations. In cases of infection, the surgical team performs copious irrigation with an antibiotic solution and debrides any necrotic tissue to ensure a clean operative field. After the removal of all components, the corporal bodies are resized, and a new prosthetic device is selected and inserted. The procedure concludes with thorough checks for functionality and leaks, followed by the closure of the incision sites. This code is distinct from CPT® Code 54410, which is used for similar procedures performed for reasons other than infection.
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The procedure described by CPT® Code 54411 is indicated for patients who require the removal and replacement of a multi-component inflatable penile prosthesis due to the presence of infection. The following conditions may warrant this surgical intervention:
The procedure for CPT® Code 54411 involves several detailed steps to ensure the successful removal and replacement of the penile prosthesis:
After the completion of the procedure, patients may require specific post-operative care to ensure proper healing and recovery. This includes monitoring for any signs of infection at the surgical site, managing pain, and ensuring that the new prosthetic device is functioning correctly. Patients may also be advised on activity restrictions and follow-up appointments to assess the healing process and the performance of the prosthesis. If a drain was placed, it will need to be monitored and possibly removed during follow-up visits. Overall, careful post-operative management is crucial for optimal recovery and the success of the procedure.
| Short Descr | REMOV/REPLC PENIS PROS COMP | Medium Descr | RMVL & RPLCMT NFLTBL PENILE PROSTH INFECTED FIEL | Long Descr | 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 | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 118 - Other OR therapeutic procedures, male genital |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| 2011-01-01 | Changed | Short description changed. Guideline information changed. |
| 2002-01-01 | Added | First appearance in code book in 2002. |
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