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The procedure described by CPT® Code 54415 involves the removal of a penile prosthesis, which can be either non-inflatable (semi-rigid) or inflatable (self-contained), without the replacement of the prosthesis. This surgical intervention is typically indicated for patients who may be experiencing complications or dissatisfaction with their existing penile prosthesis. The removal is generally performed through the same incision that was used for the initial placement of the prosthesis, ensuring minimal additional trauma to the surrounding tissues. A catheter is placed transurethrally to facilitate the procedure and maintain urinary function during the operation. The surgical technique varies slightly depending on the type of prosthesis being removed, with specific incisions and dissection methods employed to safely extract the device while preserving surrounding anatomical structures. The procedure requires careful attention to hemostasis and may involve the use of antibiotic solutions to prevent infection. In cases where infection is present, the surgical site may be left open for drainage or a drain may be inserted to manage any potential complications. The closure of the incision is performed in layers to promote optimal healing and recovery.
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The removal of a penile prosthesis, as described by CPT® Code 54415, is indicated for various reasons, including but not limited to:
The procedure for the removal of a penile prosthesis involves several detailed steps, which vary depending on whether the prosthesis is non-inflatable or inflatable:
Post-procedure care following the removal of a penile prosthesis includes monitoring for any signs of infection, managing pain, and ensuring proper wound healing. Patients may be advised to avoid strenuous activities and sexual intercourse for a specified period to allow for adequate recovery. Follow-up appointments are essential to assess the healing process and address any complications that may arise. If a drain was placed, it will need to be monitored and possibly removed during follow-up visits. Patients should also be educated on signs of complications, such as increased swelling, redness, or discharge from the surgical site, and instructed to report these to their healthcare provider promptly.
| Short Descr | REMOVE SELF-CONTD PENIS PROS | Medium Descr | RMVL NON-NFLTBL/NFLTBL PENILE PROSTH W/O RPLCMT | Long Descr | Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis | 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 | T-Packaged Codes | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | 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. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 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. | 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). | 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 | KX | Requirements specified in the medical policy have been met |
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| 2002-01-01 | Added | First appearance in code book in 2002. |
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