General Surgery Coding Alert

Reader Question:

Groin Exploration

Question: The surgeons procedure notes state: Right groin postoperative incision exploration with decom-pression of cord structures. How should I code this?
              
Idaho Subscriber
 
Answer: Although this is a procedure more often performed by urologists, general surgeons also perform it on occasion. There is no specific code for exploration with decompression of cord structures. Therefore, the correct code is 55110 (scrotal exploration). If the exploration occurred during the global period of the first procedure and required a return to the operating room, append modifier -78 (return to the operating room for a related procedure during the postoperative period) to 55110.