Urology Coding Alert

Question: The physician planned to perform a hydrocelectomy but I don’t find documentation of that in his notes. His notes speak of compressing the hemiscrotum and not decompressing any fluid. He pushed the hydrocele up into the suprapubic area. He dissected to the tunica vaginalis and hydrocele sac and says he “ended up separating it with my DeBakeys and opening up the hydrocele sac. Meticulous hemostasis was obtained with the bipolar. This decompressed the right hemiscrotum completely.” He brought the testicle back into position. There was full decompression at the completion of the procedure. Do you see evidence of a hydrocelectomy that I’m missing? There is documentation of a hernia repair during the same encounter.

Kansas Subscriber

Answer: Hydrocelectomy involves making an incision in the scrotum, draining the hydrocele fluid, excision of the hydrocele sac, and closure with stitches. The documentation you have shared does not include all of these steps.

If hydrocelectomy is performed as a standalone procedure, you would report either 55040 (Excision of hydrocele; unilateral) or 55041 (… bilateral), depending on whether it was unilateral or bilateral.

However, codes for hernia repair, such as 49500 (Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible), include hydrocelectomy if performed. You should not bill for the hydrocelectomy separately unless the hernia repair and hydrocelectomy are performed on separate sides. In that case you can bill both codes indicating the sides and append modifier 59 (Distinct procedural service) to the hydrocelectomy code.