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The procedure described by CPT® Code 54417 involves the removal and replacement of a penile prosthesis, which can be either non-inflatable (semi-rigid) or inflatable (self-contained), specifically performed through an infected surgical field during the same operative session. This complex surgical intervention is necessitated by the presence of infection, which requires careful handling of the prosthesis and surrounding tissues. The procedure begins with the placement of a catheter transurethrally to facilitate access and ensure proper drainage. The original incision used for the prosthesis insertion is reopened to allow for the exposure of the corpora cavernosa, the erectile tissues of the penis where the prosthesis is situated. Surgeons make longitudinal incisions along the dorsal surface of the corpora cavernosa to identify and access the cylinder implants. Each prosthesis, whether on the right or left side, is meticulously dissected free from the surrounding tissue and removed. In cases where the prosthesis is an inflatable semi-contained type, the tubing connected to the pump located in the sub-dartos pouch is also tracked, dissected, and removed. To manage any bleeding, hemostasis is achieved using electrocautery, and the wound is thoroughly irrigated with an antibiotic solution to minimize the risk of further infection. If the procedure is conducted through an infected field, additional care is taken to copiously irrigate the wound and debride any infected tissue as necessary. Following the removal of the infected prosthesis, a new penile prosthesis is then inserted. For non-inflatable semi-rigid prostheses, the length is measured, and appropriately sized prosthetic cylinders are loaded into an insertion device before being placed into the corporal spaces. The insertion device is subsequently removed, and the incision is closed in layers. In the case of self-contained inflatable prostheses, the replacement process involves similar steps, with the pump being inserted into the dartos pouch and connected to the cylinders. The device is then cycled to evaluate its function and check for any leaks before the corporal incisions are closed in layers. This procedure is critical for restoring function and addressing complications arising from infection.
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The procedure described by CPT® Code 54417 is indicated for patients who require the removal and replacement of a penile prosthesis due to infection. The presence of an infected prosthesis necessitates this surgical intervention to alleviate symptoms, restore function, and prevent further complications associated with the infection.
The procedure for the removal and replacement of a penile prosthesis through an infected field involves several critical steps to ensure successful outcomes. First, a catheter is placed transurethrally to facilitate drainage and access to the surgical site. The original incision used for the insertion of the prosthesis is then reopened, allowing the surgeon to expose the corpora cavernosa, the erectile tissues where the prosthesis is located. Longitudinal incisions are made along the dorsal surface of the corpora cavernosa to identify the cylinder implants. Once the implants are located, each prosthesis, whether on the right or left side, is carefully dissected free from the surrounding tissue and removed. If the prosthesis is of the inflatable semi-contained type, the tubing that connects to the pump in the sub-dartos pouch is tracked, dissected, and removed along with the prosthesis. To control any bleeding during the procedure, hemostasis is achieved using electrocautery. The wound is then irrigated with an antibiotic solution to reduce the risk of further infection. In cases where the procedure is performed through an infected surgical field, the wound is copiously irrigated, and any infected tissue is debrided as necessary to ensure a clean surgical environment. After the removal of the infected prosthesis, a new penile prosthesis is prepared for insertion. For non-inflatable semi-rigid prostheses, the length is measured, and appropriately sized prosthetic cylinders are loaded into an insertion device. These cylinders are then placed into each of the corporal spaces (right and left). Once the insertion device is removed, the incision is closed in layers. For self-contained inflatable penile prostheses, the replacement process follows similar steps. The new cylinders are inserted as described, and the pump is placed into the dartos pouch and connected to the cylinders. The device is cycled to evaluate its function and to check for any leaks. Finally, the corporal incisions are closed in layers to complete the procedure.
Post-procedure care following the removal and replacement of a penile prosthesis through an infected field includes monitoring for any signs of complications, such as infection or bleeding. Patients may be advised to follow specific wound care instructions to promote healing and prevent further infection. Follow-up appointments are essential to assess the function of the new prosthesis and to ensure that the surgical site is healing appropriately. Patients may also receive guidance on activity restrictions and any necessary medications, such as antibiotics, to support recovery.
| Short Descr | REMV/REPLC PENIS PROS COMPL | Medium Descr | RMVL & RPLCMT PENILE PROSTHESIS INFECTED FIELD | Long Descr | Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) 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.) | 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 |
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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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