Urology Coding Alert

Question: My doctor was going to perform an orchiopexy on a child, but at the time of surgery he found a migratory testicle. Since he did not do an open surgery, he wants to bill just for the examination under anesthesia. What code should I use?

California Subscriber

Answer: Your best bet is to report 45990 (Anorectal exam, surgical, requiring anesthesia [general, spinal or epidural], diagnostic), which can be for a male or female patient.

Remember: Per CPT, this code includes the following: bimanual abdominal examination, anorectal exam (45990) includes the following elements: external perineal exam, digital rectal exam, pelvic exam (when performed), diagnostic anoscopy, and diagnostic rigid proctoscopy. If your physician only did a portion of the described procedure (say the abdominal exam, but not the rectal, anoscopy, or the rigid proctoscopy) you would need to append modifier 52 (Reduced services).

Keep in mind that you'll receive a reduced fee, probably about $50-$60.

Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook.