General Surgery Coding Alert

Question: If the surgeon repairs a reducible inguinal hernia and also excises a hydrocele at the same encounter, how should we code the case?

Texas Subscriber

Answer: The answer depends on the patient age.

For a child younger than five years, you should report just one code for both procedures: 49500 (Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible).

But for a patient five years or older, you can report two codes for the two procedures, as follows:

• 49505 — Repair initial inguinal hernia, age 5 years or older; reducible
• 55040 — Excision of hydrocele; unilateral

Here’s why: A hydrocele commonly occurs with a hernia, and in pediatrics, the two are essentially the same. The mechanism and approach are the same to repair both hydrocele and hernia in infancy, so CPT^® bundles the procedures.