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2025 CPT code 54415

Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis.

Do not report this code if the prosthesis is replaced during the same session. Use the appropriate code for removal and replacement (e.g., 54416) if a new device is inserted.

Modifiers may be applicable to this code. Common modifiers include 22 (Increased Procedural Services), 52 (Reduced Services), 73 (Discontinued Procedure), 74 (Discontinued Procedure), etc. Modifier usage should be supported by appropriate documentation.

Medical necessity for removal should be clearly documented. Acceptable reasons for removal may include infection, mechanical failure, erosion, pain, or patient preference.

The physician performs the surgical removal of the penile prosthesis. This includes making an incision, dissecting the tissues around the device, removing the prosthesis, irrigating the surgical site, and closing the incision.

In simple words: The doctor removes a surgically implanted penile device used to treat erectile dysfunction. This procedure does not include putting in a new device.

Removal of a previously placed non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis. The procedure involves incision, dissection of surrounding tissues, removal of the device, irrigation, and closure. This code does not include replacement of the prosthesis.

Example 1: A patient experiences infection or mechanical complication with their inflatable penile prosthesis and requires removal of the device. A new prosthesis is not implanted during this procedure., A patient with a non-inflatable penile prosthesis desires removal of the device due to discomfort or change in personal preference. Replacement is not performed at this time., A patient with a previously placed penile prosthesis develops erosion of the overlying skin requiring removal of the device to allow for healing. Replacement is deferred until the skin has healed.

Documentation should include the type of prosthesis removed (inflatable or non-inflatable), the reason for removal (e.g., infection, mechanical complication, patient request), operative details including approach and any complications, and confirmation that no replacement prosthesis was inserted.

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