Urology Coding Alert

Modifier 51 is your key to getting paid for both procedures in 1 surgical session

When your urologist performs inguinal orchiopexies and hernia repairs in the same surgical session, you should report 54640 and one of the inguinal hernia repair codes (49495-49525) to ensure you get paid for both procedures. Don’t let the code descriptor for 54640 (Orchiopexy, inguinal approach, with or without hernia repair) confuse you.

“A large number, two-thirds or more, of young boys with cryptorchism (ICD-9 752.51, Undescended testis), have an associated hernia,” says Michael A. Ferragamo, MD, clinical assistant professor of urology, State University of New York Stony Brook. Therefore, the urologist will most likely repair both the undescended testicle and hernia at the same time. Both urologists and pediatric urologists are trained to perform both procedures, so there is no need for an additional surgeon, Ferragamo says.

54640’s Descriptor Needs Qualifying

Both the American Medical Association and the American Urological Association  state that you can bill for both the orchiopexy procedure and the hernia repair, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis. Therefore, you can report 54640 and the appropriate hernia repair code (49495-49525).

The confusion about coding orchiopexies and hernia repairs stems from the inclusion of “with or without hernia repair” in 54640’s descriptor. You might interpret this wording as implying that the code includes hernia repair. But a statement following the descriptor further complicates matters, saying, “for inguinal hernia repair performed in conjunction with inguinal orchiopexy, see 49495-49525.” So the question is: Should you report an additional code for the hernia repair, or does 54640 account for the hernia repair?

In the January 2004 CPT Assistant , Volume 14, Issue 1, the AMA stated that it is completely appropriate to bill these two codes if your urologist performs them during the same operative session: “When both orchiopexy by inguinal approach (54640) and inguinal hernia repair (49495-49525) are performed, both procedures should be reported separately. The parenthetical note clarifies that when inguinal hernia repair is performed in conjunction with inguinal orchiopexy, the coder should also see codes 49495-49525.”

Tip: CPT Codes 49491-49501 include, by description, a hydrocele repair/excision, so you can’t separately report it. But when your urologist performs the hernia repair on a patient over age 5, which you report using code 49505 (Repair initial hernia, age 5 years or over; reducible), and he performs an orchiectomy (54520) and an excision of spermatocele (54840) or an excision of a hydrocele (55040-55041), you can report each procedure separately.

Don’t Forget Modifier 51

When reporting to private payers, you will need to append modifier 51 (Multiple procedures) to the orchiopexy code to indicate that your urologist performed multiple procedures during the single surgical session. Append modifier 51 to the orchiopexy code and not the hernia repair code because the hernia repair code has the higher relative value units, 12.37 compared to 11.25 for the orchiopexy, and should be paid in full. Most carriers will reimburse one-half of the global fee for the orchiopexy.

Note: For Medicare carriers, you don’t have to use modifier 51, Hause says. Medicare will automatically acknowledge the multiple procedures. You should still list the higher fee schedule amount first, however.

Bonus: Use the cheat sheet later in this issue as your guide to coding orchiopexies and hernia repairs.

Understanding the Procedures

Orchiopexy is the treatment of freeing an undescended testicle and implanting it into the scrotum. Urologists also perform orchiopexies for retractile testes of increased mobility that move up and down between the inguinal canal and the scrotal sac, and for ectopic testes that have not descended properly and lie in an abnormal location. Undescended testicles are often associated with an indirect inguinal hernia on the same side.

An indirect inguinal hernia occurs when an opening in the inguinal canal does not close as it should before birth. As a result, abdominal tissue pushes through a weak spot in the abdominal wall in the groin area, causing a bulge in the groin or scrotum. A urologist can repair the associated indirect inguinal hernia at the same time he performs the orchiopexy.