Urology Coding Alert

Question: Is there an aspiration code specific to aspiration of the testicle or epididymis? Or do I have to use a standard aspiration code?

Michigan Subscriber

Answer: According to the available CPT codes, aspiration is aspiration, regardless of where it is performed.

Urologists perform sperm aspirations from the testicle or epididymis when males have fertility problems. To code these aspiration procedures, report code 10021 (Fine needle aspiration; without imaging guidance) or 10022 ( with imaging guidance), depending on whether imaging guidance was used to perform the aspiration.

If the urologist checks to see if the specimen is sufficient, you can also report and charge for code 88172 (Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen[s]). Regardless of whether aspiration is performed unilaterally or bilaterally, you should still report code 10021 or 10022 you don't need to append the bilateral modifier, -50 (Bilateral procedure).

Make sure the procedure your urologist performed wasn't a formal needle biopsy of the testicle, in which case you need to report the appropriate biopsy code. If it was a biopsy of the testis performed with a tru-cut type needle, you should report CPTcode 54500 (Biopsy of testis, needle [separate procedure]), or if it was an open biopsy, performed with an incision rather than with a needle, report code 54505 (Biopsy of testis, incisional [separate procedure]). You will need to append modifier -50 to the biopsy codes when the procedure is performed bilaterally.

Another option you can consider is reporting an unlisted-procedure code for the aspiration. Don't forget that you should submit the appropriate detailed documentation when reporting an unlisted-procedure code in order to substantiate reimbursement.