Urology Coding Alert

Question: A patient has a history of a scrotal wall mass for many years. Recently the mass increased in size so the urologist scheduled its surgical removal. During surgery, the mass was removed intact; it measured 7.0 x 6.5 x 5.0 cm with attached scrotal wall skin measuring 6.5 x 4.5 cm. The urologist wants to bill 55180, scrotoplasty; complicated, but I believe that code represents a more involved procedure than what the surgical report describes. The report does not point to a scrotal wall reconstruction. The final pathological diagnosis was “leiomyoma with bizarre nuclei (symplastic leiomyoma).” How should we code this case?

New York Subscriber

Answer: CPT^® code 55180 (Scrotoplasty; complicated), represents a complicated reconstruction or rebuilding of the scrotum damaged due to injury or disease. Based on the information you’ve provided from the operative report, 55180 seem inappropriate for this case.

Better option: Excision of a scrotal wall mass should lead to code 55150 (Resection of scrotum). In this procedure the provider incises the skin and subcutaneous tissue over the lesion to expose the lesion. He excises the tumor within the scrotal wall as well as a margin of surrounding normal scrotum. The provider irrigates the wound and closes the incision by suturing the layers of scrotal wall tissue together. Check your complete op-report for the procedure performed and select the code accordingly.