2025 CPT code 54416
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Surgical Procedures on the Male Genital System - Repair Procedures on the Penis Surgery Feed
Removal and replacement of a non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis during the same operative session.
Modifiers may be applicable depending on the circumstances of the procedure (e.g., 51 for multiple procedures, 22 for increased procedural services, 52 for reduced services). Consult the CPT guidelines for appropriate modifier usage.
Medical necessity for the replacement of a penile prosthesis is established by evidence of prosthesis malfunction (e.g., mechanical failure, infection, erosion), which results in pain, dissatisfaction, or inability to achieve penile erection.
The surgeon is responsible for all aspects of the procedure, including patient preparation, anesthesia administration (if applicable), making the incisions, dissecting the tissues, removing the old prosthesis, inserting the new prosthesis, and closing the incisions.
In simple words: The doctor removes and puts in a new artificial penis implant during one surgery. This is for men who already have an implant and need it replaced.
This CPT code, 54416, encompasses the surgical removal and replacement of a previously implanted penile prosthesis within a single operative session.The procedure involves removal of a non-inflatable (semi-rigid) or self-contained inflatable penile prosthesis.This entails an incision, typically near the pubic bone or on the underside of the penis, followed by dissection of tissues to access and remove the prosthesis from the corpora cavernosa.A new prosthesis is then inserted, advanced to the mid-glans and positioned along the penile shaft. The corporotomy and incisions are subsequently closed with sutures. The type of prosthesis inserted, not removed, dictates code selection.
Example 1: A 60-year-old male patient presents with a malfunctioning semi-rigid penile prosthesis, experiencing pain and difficulty with erection. The surgeon performs a removal and replacement of the prosthesis with a new semi-rigid device within the same operative session., A 55-year-old male patient experiences mechanical failure of his self-contained inflatable penile prosthesis.During a single surgical intervention, the surgeon removes the malfunctioning device and replaces it with another self-contained inflatable prosthesis., A 72-year-old male patient reports infection at the site of his previously implanted semi-rigid penile prosthesis. The surgeon removes the infected prosthesis and replaces it with a new, infection-resistant model, all during a single surgery.
* Preoperative assessment including patient history, physical examination, and imaging studies (if necessary) to determine prosthesis malfunction or infection.* Operative report detailing the procedure, including type of prosthesis removed and replaced.* Intraoperative photographs of the surgical field before and after placement of the new prosthesis.* Postoperative care instructions and follow-up schedule.* Pathology reports (if infection was present).
** Always refer to the most current CPT codebook and payer guidelines for accurate coding and reimbursement.Documentation must clearly support the medical necessity and the specific details of the procedure.
- Revenue Code: P1G (Major Procedure - Other)
- RVU: This information is not available in the provided source. Consult the current year's CPT codebook or a reliable medical billing resource for RVU data.
- Global Days: This information is not provided in the source.The global period will depend on payer specific guidelines and may vary.
- Payment Status: Active
- Modifier TC rule: The application of a technical component (TC) modifier depends on the specific circumstances of the procedure and may vary by payer guidelines.
- Fee Schedule: Fee schedule data is not available within this source.Consult the most up-to-date fee schedules from your payer(s) and local area.
- Specialties:Urology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Outpatient Hospital