Urology Coding Alert

Plus: Don't confuse varicocele with hydrocele.

A varicocele is an abnormal dilation of spermatic cord veins in the scrotum. Varicoceles can be very painful; the pain is only relieved when the veins are ligated or the varicocele is excised.

CPT^® 2018 includes only a few codes specific to varicocele excision, but you'll need to watch certain details before making your final selection. Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York in Stony Brook, tells you how to choose from the potential options:

• 55530 – Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure)
• 55535 – ... abdominal approach
• 55540 – ... with hernia repair
• 55550 – Laparoscopy, surgical, with ligation of spermatic veins for varicocele.

Pinpoint the Surgeon's Approach

Start your coding quest by confirming which type of approach the surgeon used during excision, Ferragamo says. You will also want to note whether other procedures took place during the same operative session.

Your options include:

• 55530 when the urologist removes the varicocele through an incision in the upper scrotum or via an inguinal incision. Code 55530 represents a standalone procedure, so do not report it when the varicocele removal is part of a larger, related service.
• 55535 when the urologist makes an incision in the lower abdomen to reach the varicocele
• 55540 when the procedure to excise the varicocele also includes a hernia repair
• 55550 when the urologist uses a laparoscopic approach to ligate the spermatic veins and excise the varicocele.

Important: There is really no set number of veins ligated during a varicocelectomy, which you report with 55530. You may consider adding modifier 22 (Increased procedural services) if the extra ligation of veins did significantly prolong the procedure or make the surgery more complicated. The surgeon would be the best one to determine this. Most often the extra vein ligation does not really prolong the surgery or complicate the general procedure.

Assign the Correct Diagnosis

When it's time to assign a diagnosis for varicocele removal, don't confuse the clinical condition with a hydrocele.

The difference: A hydrocele occurs when fluid collects in the thin sheath surrounding a testicle (known as the tunica vaginalis). Although varicoceles and hydroceles both involve swelling, the cause and affected areas are different.

Whichever approach the urologist uses, you only need to remember one diagnosis for varicocele excision: I86.1 (Scrotal varices). The correct diagnosis for a hydrocele of the spermatic cord or testis is N43.3 (Hydrocele, unspecified).

Watch the Documentation

Varicocele excision is performed most often to reverse male infertility. A slight increase in intra-scrotal temperature caused by the dilation of the spermatic cord veins often results in infertility, so the excision of the varicocele often restores male fertility.

Take note: Ferragamo warns that some insurance payers may not reimburse for a varicocelectomy with the associated diagnosis of male infertility (N46.8, Other male infertility). However, the insurer will pay for the excision of a varicocele with the diagnosis of scrotal varices (I86.1). Therefore, one must be very careful with diagnostic codes and supporting documentation. The case must be clearly documented to show that the procedure is medically necessary.