2025 CPT code 54411

Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue.

Refer to the official CPT coding guidelines for detailed instructions on appropriate use of this code.Pay particular attention to guidelines for reporting reduced services (modifier 52) and the inclusion of additional codes where appropriate (such as those for infection management).

Modifiers such as 52 (reduced services) may be appropriate depending on the extent of the services performed.Consult the CPT manual and your payer's guidelines for appropriate modifier usage.

Medical necessity for this procedure would be established by documentation of mechanical failure, infection, or other complications related to the existing penile prosthesis, rendering the implant non-functional or causing significant patient distress.Supporting documentation may include imaging studies, laboratory results, and clinical notes illustrating the need for prosthesis revision.

The clinical responsibility involves the surgeon performing the entire procedure, including prepping the patient, making incisions, removing old components, inserting new components, irrigating and debriding infected tissue, checking prosthesis function, and closing the incisions.

IMPORTANT For reduced services, report 54411 with modifier 52.Do not report 11042, 11043 in addition to 54411. For other urethroplasties, see 53400-53430. For penile revascularization, use 37788. If a different type of prosthesis is inserted, consider codes 54410, 54416, and 54417.

In simple words: The doctor removes and replaces a three-part inflatable penile implant during one operation.This includes removing the old parts, cleaning any infection, and putting in new parts. The doctor then makes sure the new implant works correctly.

This CPT code, 54411, describes the surgical removal and replacement of all components of a multi-component inflatable penile prosthesis during a single operative session.The procedure involves the removal of the cylinders from the corpora cavernosa, followed by the insertion of new deflated cylinders via the glans penis.The corporotomy is closed, and any infected tissue is irrigated and debrided with an antibiotic solution. The reservoir and pump are also replaced, and the functionality of the entire prosthesis is checked. The procedure concludes with tissue closure and catheter removal (if applicable).

Example 1: A 60-year-old male patient presents with an infected multi-component inflatable penile prosthesis. The surgeon performs a complete removal and replacement of the prosthesis, including irrigation and debridement of the infected tissue. This scenario aligns with the description of 54411., A 55-year-old male patient experiences mechanical failure of his multi-component inflatable penile prosthesis. During the revision surgery, the surgeon removes the old device completely, addresses any infection that may be present, and implants a new multi-component inflatable prosthesis.Code 54411 accurately reflects this scenario., A 70-year-old male patient has a malfunctioning multi-component inflatable penile prosthesis.The surgeon removes the device, noting an infection present. The surgeon thoroughly cleans the infected area and then implants a new device of the same type. This surgical intervention is correctly captured using code 54411.

Detailed operative report specifying the removal and replacement of all components (cylinders, reservoir, pump).Documentation should include details on irrigation and debridement of infected tissue, type of prosthesis used, and confirmation of prosthesis functionality post-operatively. Pre-operative and post-operative diagnoses are also essential.

** Careful review of the operative report is crucial for accurate coding.The type of prosthesis inserted (and not the type removed) is the key factor for code selection.Consider modifier 52 (reduced services) if indicated. This code is for complete removal and replacement.

  • Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
  • RVU: This information is not available in the provided text.Consult the current CPT codebook and your payer's fee schedule for RVU and reimbursement information.
  • Global Days : The global period for this procedure is not specified in the provided text.Refer to the CPT manual and your payer's guidelines for details.
  • Payment Status: Active
  • Modifier TC rule: The provided data does not specifically address the application of a Technical Component (TC) modifier.Consider your payer's specific guidelines to determine TC modifier applicability.
  • Fee Schedule : This information is not available in the provided text. Consult your payer's fee schedule for historical and current reimbursement data.
  • Specialties:Urology
  • Place of Service:Ambulatory Surgical Center, Inpatient Hospital, Outpatient Hospital
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