Urology Coding Alert

Question: My urologist documents performing a "right groin postoperative incision with decompression of cord structures." How does this translate into a CPT code, and are there any special requirements for reporting this procedure?

Idaho Subscriber

Answer: This is an interesting question. If the decompression of the cord structures are secondary to postoperative hemorrhage within the cord, or edema from thrombosis of cord vessels or localized infection, use 35840 (Exploration for postoperative hemorrhage, thrombosis or infection; abdomen).

Because the exploration and decompression was performed during the postoperative period of another procedure, you may need to append modifier -78 (Return to operating room for a related procedure during the postoperative period) to 35840. Don't forget that modifier -78 has specific requirements for use, including the stipulations that the postoperative procedure be performed in what is considered an operating room or endoscopy suite in a hospital, or ambulatory surgical center, and also that the postoperative procedure be related to or in response to a complication of the initial procedure.