2025 CPT code 54410

Removal and replacement of all components of a multi-component, inflatable penile prosthesis during the same surgical session.

Follow the official CPT coding guidelines and payer-specific rules when applying 54410.Accurate documentation is crucial for proper coding and reimbursement.Consider modifier 52 if the procedure is incomplete. Pay close attention to whether all components were actually removed and replaced.

Modifiers may be applied depending on the specifics of the procedure and payer requirements.For example, modifier 52 (reduced services) could be used if not all components were replaced.Other modifiers (e.g., 22, 58) may be appropriate in specific circumstances; consult payer guidelines and the official CPT guidelines.

Medical necessity is established by the presence of mechanical failure, infection, pain, or other complications related to the existing prosthesis that necessitate removal and replacement for improved erectile function and patient well-being. The documentation should fully support the need for the procedure.Appropriate ICD-10 codes must also be documented.

The urologist or a qualified surgeon is responsible for the pre-operative assessment, performing the surgical removal and replacement of the penile prosthesis, ensuring proper functionality, and providing post-operative care.

IMPORTANT If only some components are removed or replaced, or if a different type of prosthesis is implanted, other CPT codes (e.g., 54411, 54408, 54406, 54415) may be more appropriate.Modifier 52 (Reduced Services) may be used if not all components are removed and replaced.For penile revascularization, use 37788.

In simple words: The doctor removes and replaces all parts of an existing inflatable penis implant during one surgery. This involves taking out the old implant and putting in a new, identical one.

This CPT code encompasses the complete removal of all components (cylinders, reservoir, and pump) of a previously implanted multi-component inflatable penile prosthesis, followed by the immediate replacement with an identical prosthesis during a single operative session.The procedure involves accessing the prosthesis via incision, removing the existing components from the corpora cavernosa, and replacing them with new components.Functionality is verified through inflation and deflation testing.The procedure concludes with tissue closure and catheter removal (if applicable).

Example 1: A 60-year-old male patient experiences mechanical failure of his previously implanted three-piece inflatable penile prosthesis.The surgeon performs a complete removal and replacement of all components during a single surgical session., A 55-year-old male patient presents with infection related to his previously placed three-piece inflatable penile prosthesis.The surgeon removes the infected prosthesis and replaces it with a new, identical prosthesis.Irrigation and debridement are performed (though this would be coded differently)., A 70-year-old patient undergoes removal and replacement of his three-piece inflatable penile prosthesis due to persistent pain and discomfort.A new prosthesis of the same type is implanted.The initial reservoir is left in.

* Pre-operative assessment documenting the need for prosthesis removal and replacement.* Operative report detailing the removal and replacement of all prosthesis components.* Intraoperative images (if obtained).* Post-operative assessment confirming prosthesis functionality and absence of complications.* Pathology report (if tissue is sent for analysis).

** The accuracy of coding depends heavily on complete and precise documentation of the procedure.Any discrepancy between the description and the actual procedure performed may lead to coding errors and claim denials. This code is specifically for replacement with the *same* type of implant.If a different type of implant is used, different codes will apply.

  • Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
  • RVU: This information is not included in the provided text.RVUs vary based on geographic location and other factors. Consult a relevant fee schedule for current values.
  • Global Days : The global period for this procedure is not specified in the provided text.Consult the appropriate payer guidelines for clarification.This will likely depend upon the facility type and payer.
  • Payment Status: Active
  • Modifier TC rule: The information provided does not specify whether a technical component (TC) modifier is applicable. Refer to payer guidelines and the official CPT guidelines for clarification.
  • Fee Schedule : Historical fee schedule data is not included in the provided text.Consult a reputable fee schedule database for historical data.
  • Specialties:Urology
  • Place of Service:Ambulatory Surgical Center, Hospital (Inpatient or Outpatient), Office
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