Summary & Overview
HCPCS C1813: Prosthesis, Penile, Inflatable
HCPCS Level II code C1813 denotes an inflatable penile prosthesis — an implanted device used to restore erectile function when other therapies are ineffective. Nationally, this code is relevant for urology, sexual medicine, and surgical specialty billing, and it has implications for device coverage, prior authorization processes, and reimbursement for prosthetic implants.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code’s clinical context, typical site-of-service use (operating room or ambulatory surgical center), common modifiers, and payer coverage patterns where available. The publication summarizes benchmark payment considerations, coding nuances for device implantation claims, and procedural documentation elements that influence claim adjudication.
The summary provides practical reference points for revenue cycle, clinical coding, and payer policy teams seeking to align clinical documentation with claim submission for penile inflatable prosthesis services. Data not available in the input is noted where applicable.
Billing Code Overview
HCPCS Level II code C1813 describes a prosthesis, penile, inflatable. This code represents an implanted medical device used to treat erectile dysfunction by providing an inflatable penile prosthesis that can be manually inflated and deflated by the patient.
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Service type: Surgical implant/prosthetic device placement
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Typical site of service: Operating room or ambulatory surgical center (inpatient or outpatient surgical settings may apply)
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Clinical & Coding Specifications
Clinical Context
A 58-year-old male with long-standing diabetes mellitus and peripheral vascular disease presents with irreversible erectile dysfunction refractory to phosphodiesterase type 5 inhibitors and intracavernosal injections. After urologic evaluation including history, physical exam, and counseling about risks and expectations, the patient is scheduled for implantation of an inflatable penile prosthesis (C1813) in an ambulatory surgical center under general or regional anesthesia. The clinical workflow includes preoperative medical clearance, informed consent, perioperative antibiotic prophylaxis, placement of the three-component inflatable device with reservoir and pump, intraoperative testing of device function, and postoperative instructions for wound care and device activation typically delayed 4–6 weeks. Typical sites of service are the ambulatory surgical center and hospital operating room. Follow-up visits include incision check within 7–14 days and device activation and teaching at the postoperative visit.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when work required is substantially greater than usual (e.g., complex revision with extensive fibrosis). |
52 |