Urology Coding Alert
Submit 10021 or 10022 for Epididymal Cyst Aspiration
Question: The urologist used ultrasound guidance to evaluate the epididymis and multiple cysts within it (there were three prominent cysts, the largest being 3 cm). The echotexture of the testicles was normal bilaterally, and there was no evidence of mass or nodularity. Should I code 55000 for aspiration of the epididymal cysts? Montana Subscriber Answer: No, based on your description, code 55000 (Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication) is incorrect for this procedure. Code 55000 represents aspiration of a hydrocele, but your physician aspirated an epididymal cyst. The more appropriate code is either 10021 (Fine needle aspiration; without imaging guidance) or 10022 (... with imaging guidance), depending on whether imaging guidance was used to perform the aspiration. Since imaging guidance was used, code 10022 would seem appropriate for this clinical scenario. The correct ICD-10 diagnosis would be N50.3 (Epididymal cyst).
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