Urology Coding Alert

Reader Question:

Removal of a Spermatocele and Partial Removal of Epididymis

Question: The urologist removed the head of the epididymis for an epididymal cyst, a spermatocele. He wants to bill with 54860. Should I bill with modifier 52 since he left the rest of it attached to the testis?

New Jersey Subscriber

Answer: No, bill the procedure with code 54840 (Excision of spermatocele with or without epididymectomy). This code does not indicate a complete epididymectomy or only a partial epididymectomy, head, of the epididymis. 


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