Urology Coding Alert

Question: An abscess formed after a patient underwent vasectomy. The urologist performed an I&D, but the infection returned. Notes from the follow-up surgery stated, "A portion of the distal spermatic cord, a sperm granuloma, was removed and the spermatic cord ligated with a 0 chromic stitch. We also debrided a small amount of tissue from the skin. No large pocket of pus was found on full exploration." I'm considering codes 55120, 11004, and 55110. I know that some of the codes need modifiers if reported together. What is your advice?

North Carolina Subscriber

Answer: The appropriate code is 55120 (Removal of foreign body in scrotum). Append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) since you are coding for an unplanned return to the operating room and further surgery due to complications occurring during the 90-day global of the vasectomy.

CPT^® codes 11004 (Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum) and 55110 (Scrotal exploration) are considered to be included in the work of 55120 unless the surgeon makes a separate incision.