2025 CPT code 54406

Removal of all components of a multi-component, inflatable penile prosthesis without replacement.

Refer to the most current CPT® coding manual for complete guidelines.

Modifiers 52 (reduced services) can be used if not all components are removed. Other modifiers may be applicable depending on the circumstances.

Removal of a penile prosthesis is medically necessary when there is device malfunction, infection, pain, or patient dissatisfaction.Documentation should clearly demonstrate these reasons.

The urologist or surgeon is responsible for the preoperative preparation, surgical removal of the penile prosthesis components, closure of the incision, and postoperative care.Anesthesiologist may also be involved.

IMPORTANT For reduced services, use 54406 with modifier 52.If the prosthesis is non-inflatable or self-contained, consider 54415. For penile revascularization, use 37788.

In simple words: The doctor removes a previously implanted device used to help with erectile dysfunction. This involves taking out all parts of the device and doesn't include putting in a new one.

This procedure involves the complete removal of a multi-component inflatable penile prosthesis, including the cylinders from the corpora cavernosa, the reservoir from the deep pubic bone area, and the pump from the scrotum.The procedure does not include replacement of the prosthesis.The surgical site is closed with sutures, and any existing catheter is removed.

Example 1: A patient experiences recurrent infections related to a multi-component inflatable penile prosthesis. The surgeon removes all components of the device., A patient is dissatisfied with the functionality of their multi-component inflatable penile prosthesis and requests removal., Mechanical failure of a multi-component inflatable penile prosthesis necessitates complete removal.

* Preoperative assessment including patient history, physical examination, and imaging studies (if needed).* Operative report detailing the procedure, including the specific components removed.* Postoperative assessment and documentation of any complications.* Medical records supporting the medical necessity of the removal.

** Accurate coding requires precise documentation specifying the type of prosthesis removed and the reason for removal.Always confirm payer-specific coding and reimbursement policies.

  • Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
  • RVU: The relative value units will vary based on geographic location and payer.Consult the relevant fee schedule for specific RVU values.
  • Global Days : The global period is not specified for this code; it should be determined based on payer-specific guidelines and the complexity of the procedure.
  • Payment Status: Active
  • Modifier TC rule: A technical component (TC) modifier is not applicable to this code.
  • Fee Schedule : Fee schedules vary based on payer and location. Refer to payer-specific fee schedules for historical data.
  • Specialties:Urology
  • Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Office
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