Urology Coding Alert

Question: How should I report the removal of a testicular prosthesis from the patient’s scrotum?


Nevada Subscriber

Answer: For the removal of a testicular prosthesis from the scrotum, you should report 55120 (Removal of foreign body in scrotum). In this case, because CPT does not have a more appropriate code that identifies the type of foreign body (a prosthesis), this less descriptive code is appropriate.

The diagnosis code you’ll use depends on the reason that the urologist had to remove the prosthesis.

Option 1: If the prosthesis removal occurred because the prosthesis became infected, you should use 996.65 (Infection and inflammatory reaction due to internal prosthetic device, implant, and graft; due to other genitourinary device, implant and graft).

Option 2: If the urologist performed the procedure because of persistent pain secondary to the presence of the prosthesis, a complication, report 996.76 (Other complications of internal prosthetic device; pain due to genitourinary device, implant and graft).