Urology Coding Alert

Question: My urologist is performing a hydrocelectomy (CPT 55040) . If he also excised a spermatocele during the same encounter, is this billable with a 54840 and a 51 or 59? Or would I consider it inclusive to the hydrocelectomy. If it is inclusive, in what instance would you use 54840?

Ohio Subscriber

Answer: For a spermatocelectomy you should use 54840 (Excision of spermatocele, with or without epididymectomy). The Correct Coding Initiative (CCI) bundles 54840 into 55040 (Excision of hydrocele; unilateral) with a modifier indicator of "1," indicating that you can bypass this edit with a modifier under specific circumstances. Therefore, determining whether you can report both codes will depend on how much additional surgery was required to remove the "spermatocele."

If both the spermatocele and the hydrocele are large and take a significant amount of time for removal of both, as is often the case, then bill for both. First, report 55040. Then, report 54840 with modifier 59 (Distinct procedural service) appended to bypass the above mentioned edit.