Urology Coding Alert

Hint: Include the infectious agent with code N43.1.

When your urologist diagnoses a hydrocele, you must check for several details in the medical documentation, including the specific type of hydrocele and whether its communicating or non-communicating. If you don’t know this information, you may choose the incorrect code.

Answer commonly asked questions to help you sort through the hydrocele ICD-10-CM and CPT^® codes you may encounter in your urology practice.

First, Define Hydrocele for Clarity

Question 1: What is a hydrocele?

Answer 1: A hydrocele is a fluid-filled sac surrounding a testicle that causes swelling in the scrotum. Hydroceles are common in newborn males, especially premature infants. However, hydroceles can also occur in older males during puberty and in adults.

Oftentimes, hydroceles in newborn males will improve and resolve/disappear spontaneously on their own as the connecting channel with the peritoneal cavity closes, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook. However, if the hydrocele doesn’t improve, your urologist may have to perform a surgical correction.

Pinpoint Correct Hydrocele ICD-10-CM Codes

Question 2: What ICD-10-CM codes should I look to for hydroceles?

Answer 2: When your urologist diagnoses a hydrocele, you must check the documentation to see what specific type the patient has. Then you can look to the following ICD-10-CM codes:

• N43.0 (Encysted hydrocele)
• N43.1 (Infected hydrocele)
• N43.2 (Other hydrocele)
• N43.3 (Hydrocele, unspecified)

Differentiate Between Communicating and Non-Communicating

Question 3: What does it mean if a hydrocele is communicating or non-communicating?

Answer 3: Hydroceles are classified as either communicating or non-communicating.

Communicating hydrocele defined: A communicating hydrocele has contact (communication) with the fluids of the patient’s abdominal peritoneal cavity. A communicating hydrocele is caused by the processus vaginalis failing to close completely during prenatal development. If this membrane remains open, the patient could potentially also develop a hernia as well as a hydrocele. Communicating hydroceles are seen most often in male infants and very young male children.

Non-communicating hydrocele defined: A non-communicating hydrocele does not communicate with the abdominal peritoneal cavity. A non-communicating hydrocele might be present at birth or might develop years later for no obvious reason. A non-communicating hydrocele usually remains the same size or has a very slow growth.

Don’t miss: Another term for a non-communicating hydrocele is an “encysted hydrocele,” so if you see this diagnosis in your urologist’s documentation, you should report code N43.0 as the diagnosis.

Don’t Forget to Include Infectious Agent With N43.1

Question 4: The patient has an infected hydrocele, so I reported N43.1 on my claim, but my colleague says that I need to include another code as well. I am new to urology and have no idea what she is talking about. Can you help me?

Answer 4: In the ICD-10-CM Manual, if you look under code N43.1, you will see instructions to include an additional code from categories B95- through B97- to identify the infectious agent if known. Codes B95-B97 represent bacterial and viral infectious agents:

• B95 (Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere)
• B96 (Other bacterial agents as the cause of diseases classified elsewhere)
• B97 (Viral agents as the cause of diseases classified elsewhere)

Find Out Patient’s Age When Reporting Hydrocele Excision With Hernia Repair

Question 5: If my urologist repaired a reducible inguinal hernia and also excised a hydrocele during the same encounter, what CPT^® codes should I report on my claim?

Answer 5: You will report the appropriate code depending upon the patient’s age.

For a child younger than 5 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).

For a patient 5 years or older, you can report the following two codes for the two procedures:

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

Don’t miss: A hydrocele commonly occurs with a hernia, and in pediatrics, the two are considered essentially the same. The mechanism and approach are the same to repair both hydrocele and hernia in infancy, so CPT^® bundles these procedures.

Include Removal of Vasectomy Clip in This Scenario

Question 6: My urologist performed a left hydrocelectomy with excision of right sperm granuloma and extraction of a vasectomy clip on the left side. What CPT^® codes should I list on my claim?

Answer 6: You should first report 55520 (Excision of lesion of spermatic cord [separate procedure]) for the removal of the sperm granuloma. Then, you should report 55040 (Excision of hydrocele; unilateral) for the excision of the hydrocele. You may also bill the removal of the vasectomy clip, a foreign body in the scrotum, with code 55120 (Removal of foreign body in scrotum).