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The procedure described by CPT® Code 54416 involves the removal and replacement of a penile prosthesis, which can be either non-inflatable (semi-rigid) or inflatable (self-contained), all performed during the same surgical session. A penile prosthesis is a medical device implanted to treat erectile dysfunction, providing a means for achieving an erection. The procedure begins with the placement of a catheter through the urethra to facilitate access and maintain urinary function during the operation. The surgeon reopens the incision made during the initial prosthesis insertion to access the corpora cavernosa, the erectile tissue of the penis. Longitudinal incisions are made along the dorsal surface of the corpora cavernosa to expose the existing prosthetic implants. Each prosthesis is carefully dissected from the surrounding tissue and removed. If the prosthesis is of the inflatable type, the tubing connected to the pump is also removed. The surgical field is meticulously cleaned, and hemostasis is achieved using electrocautery to prevent excessive bleeding. If the procedure is conducted in an infected area, additional steps such as copious irrigation and tissue debridement are performed to ensure a clean surgical environment. Following the removal, the new prosthesis is inserted, with specific techniques varying based on whether the prosthesis is semi-rigid or inflatable. The procedure concludes with the closure of the incision in layers, ensuring proper healing and function of the newly implanted device.
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The procedure described by CPT® Code 54416 is indicated for patients requiring the removal and replacement of a penile prosthesis due to various reasons, which may include:
The procedure for the removal and replacement of a penile prosthesis involves several detailed steps:
After the procedure, patients are typically monitored for any immediate complications, such as bleeding or infection. Post-operative care may include pain management and instructions for activity restrictions to promote healing. Patients are advised on the care of the surgical site and when to follow up with their healthcare provider to assess the function of the new prosthesis and ensure proper recovery. It is essential to monitor for any signs of infection or complications during the recovery period.
| Short Descr | REMV/REPL PENIS CONTAIN PROS | Medium Descr | RMVL & RPLCMT NON-NFLTBL/NFLTBL PENILE PROSTHESI | Long Descr | Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session | 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 | ASC Payment Indicator | Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate. | 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). | 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.) | 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 | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition |
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| 2013-01-01 | Changed | Medium Descriptor changed. |
| 2002-01-01 | Added | First appearance in code book in 2002. |
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