Urology Coding Alert

If your urologist works with another surgeon, be sure you know when to employ a modifier.

Often, urologists perform an orchiopexy and inguinal hernia repair in the same session. Choosing the proper coding can be a challenge because several variables can affect which codes you will use.

Read on to find out how testicle location, hernia repair, and working with another surgeon can all affect the codes you report.

1. Determine Reason Behind the Procedure

Orchiopexy is the procedure of freeing an undescended testicle and implanting it permanently into the scrotum. Urologists also perform orchiopexies for retractile testes with increased mobility that move up and down between the inguinal canal and the scrotal sac and for ectopic testes that have not descended properly and lie in an abnormal location. Undescended testicles are often associated with an indirect inguinal hernia on the same side, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook.

Determining the reason for the procedure is your first step toward choosing a CPT® code to report.

Undescended intra-abdominal testis: This is a common scenario for a laparoscopic orchiopexy, frequently performed in a young child with an undescended testicle lying within the abdomen. For moving the intra-abdominal undescended testicle down into the scrotum laparoscopically, you should report 54692 (Laparoscopy, surgical; orchiopexy for intra-abdominal testis), recommends Karla Dickerson, billing and reimbursement coordinator at Salina Urology Associates in Kansas. Use ICD-9 code 752.51 (Undescended testis).

If performing an open orchiopexy for an intra-abdominal undescended testicle, report 54650 (Orchiopexy, abdominal approach, for intra-abdominal testis [e.g., Fowler-Stephens]).

"An undescended testicle may also be found, trapped, within the inquinal canal unable to complete its normal passage into the scrotum," Ferragamo says. Use the open procedure code 54640 (Orchiopexy, inguinal approach, with or without hernia repair) for an orchiopexy via an open inguinal approach. Link this procedure also with 752.51.

Exploration: When an inguinal or abdominal exploration fails to reveal a testicle, as in absent testicle syndrome (752.89, Other specified anomalies of genital organs…monorchism), use 54550 (Exploration for undescended testis, inguinal or scrotal area), 54560 (Exploration for undescended testis with abdominal exploration), or 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), says Christy Shanley, CPC, department administrator for the University of California, Irvine department of urology.

Retractile testis: Your urologist may occasionally perform orchiopexy transcrotally for a retractile testis (a testis that moves up and down). In these cases, report 54600 (Reduction of torsion of testis, surgical, with or without fixation of contralateral testis) with modifier 52 (Reduced services) appended because torsion reduction is not performed. Link this procedure with 752.52 (Retractile testis).

Ectopic testis: Usually this testis has partially descended but not along a normal path. Instead of residing in the scrotum, when the testis passes through the external inguinal ring, it descends pathologically into the perineum, the penis, the femoral area, or the subcutaneous tissues, the pouch of Douglas. Use 54640 (Orchiopexy, inguinal approach, with or without hernia repair) for this repair. Append ICD-9 diagnostic code 752.51, the diagnosis code specified for ectopic testis.  

2. Check for Hernia Repair During the Same Session

Many times an orchiopexy is performed along with a hernia repair. Determining whether you need a hernia repair code, and if so, which one is the next step in your coding process.

"An indirect inguinal hernia occurs when an opening in the processus vaginalis, a communication between the peritoneal cavity and the small sac around the testicle, does not close as it should before birth," Ferragamo explains. "As a result, intestine and abdominal tissue may pass through this open process into the groin or scrotum at times causing a bulge in the groin or scrotum." Your urologist can repair the associated indirect inguinal hernia at the same time he performs the orchiopexy. 

When your urologist performs an inguinal hernia repair in conjunction with an inquinal orchiopexy, code both the hernia repair (49495-49525) as well as the orchiopexy. For most laparoscopic hernia repairs, you’ll report 49650 (Laparoscopy, surgical; repair initial inguinal hernia).

Hernia repair performed with orchiopexy is most often on the same side as the undescended testicle although on occasion bilateral hernias have been seen with both hernias requiring repair at the same time as the orchiopexy, Ferragamo says. An intra-abdominal undescended testicle is not usually associated with an accompanying hernia. "Here the lack of an open processus vaginalis in fact may be one reason the testicle did not descend," Ferragamo says.

Coding scenarios: When your urologist uses a laparoscopic procedure for an intra-abdominal undescended testis, bill 49650 for the laparoscopic hernia repair and 54692 for the laparoscopic orchiopexy, Dickerson says. Bill 54692 on the first line, and 49650 with modifier 51 appended, on the second line, because 54692 has a relative value unit (RVU) of 22.49, compared to 12.46 for 49650.

For an open inquinal hernia repair and an ipsilateral orchiopexy, report the hernia repair with 49505 (RVUs of 15.15) on the first line and the orchiopexy with 54640 (RVUs of 14.17) on the second line.

Diagnosis help: Use 550.90 (Inguinal hernia, without mention of obstruction or gangrene; unilateral or unspecified [not specified as recurrent]) for the hernia repair, and 725.51 for the orchiopexy. Diagnosis codes for hernias are broken down by site; urologists typically use the inguinal hernia diagnostic codes (550.9x for those with testicles are not broken down by site.

Add modifiers LT (Left side) and RT (Right side) to the appropriate code. This is optional, however, because both code descriptors are unilateral and neither is bundled into the other, but using modifiers LT and RT would more fully describe the procedures performed.

If your urologist performs the procedures bilaterally, don’t forget to attach modifier 50 (Bilateral services) and use the bilateral diagnosis for the hernia, 550.92 (Bilateral inguinal hernia without obstruction or gangrene), Shanley explains.

Tip: The urologist may be able to use the same ports when performing a simultaneous laparoscopic hernia repair and an orchiopexy. This will have no effect on the coding.

You may find the "with or without hernia repair" verbiage in 54640 confusing when coding an orchiopexy and a hernia repair. Code 54640 describes an inguinal approach for an open orchiopexy. A parenthetical note under 54640 in CPT® states: "For inguinal hernia repair performed in conjunction with inguinal orchiopexy, see 49495-49525." Therefore, when performing an inguinal orchiopexy and concurrent hernia repair, report 54640 and the appropriate hernia repair code (49495-49525) with modifier 51 appended to the hernia repair code.

3. Append a Modifier When Working With Another Surgeon

Scenario: A urologist and a general surgeon each performed surgery on the same patient at the same encounter. The urologist did an orchiopexy and performed the opening and closing. The general surgeon performed an inguinal hernia repair.

CPT® and the Correct Coding Initiative (CCI) do not bundle these two procedures. In fact, as indicated above, if your urologist performed both the hernia repair and the orchiopexy without another physician, you could report both procedure codes.

For this scenario when two surgeons are involved, however, each physician will report his portion of the procedure. The general surgeon will report the appropriate inguinal hernia repair code -- such as 49500 (Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible) or 49505 (… age 5 years or older; reducible). As the urologist’s coder, you will code the applicable orchiopexy code (54640).

Beware: You should not use modifier 62 (Two surgeons). You would only report co-surgeons (using modifier 62) if the surgeons worked together on the same procedure, each performing a portion of the total procedure, and both reporting the same CPT® code, Ferragamo explains. Each physician would document in separate operative reports the part or portion of the total procedure he performed.

Consider 80: Many non-Medicare carriers will reimburse for assistant surgeon charges when two surgeons performing separate procedures at the same operative encounter also assist each other. Append modifier 80 (Assistant surgeon) to the surgical code (as long as the surgical codes allow for an assistant surgeon). Note that Medicare will not pay for an assistant surgeon if both surgeons perform major procedures at the same encounter.