Urology Coding Alert

Report I86.1 for varicoceles.

In some cases, your urologist may need to perform an excision of a varicocele. When your urologist performs this type of procedure, you must check and make sure you can identify the type of approach they used.

Follow these handy tips to keep your varicocele excision coding in tip-top shape.

Tip 1: First, Define Varicocele for Clarity

A varicocele is an abnormal dilation of spermatic cord veins, called the pampiniform plexus, in the scrotum. The scrotum is the pouch of skin that holds the testicles.

Varicoceles can be very painful, and the pain is only relieved when your provider ligates the veins or excises the varicocele.

Tip 2: Focus on These Codes for Varicocele Excision

You have several CPT^® codes to choose from for varicocele excision. When it comes to understanding the difference between the following codes, you must double-check the medical documentation to confirm which type of approach your urologist used during the excision. You should also note whether other procedures took place during the same operative session:

• 55530 (Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure)). Note: You should report 55530 when your urologist removes the varicocele through an incision in the upper scrotum or via an inguinal incision. Since 55530 represents a standalone procedure, you should not report it when the varicocele removal is part of a larger, related service.
• 55535 (Excision of varicocele or ligation of spermatic veins for varicocele; abdominal approach). Note: You should report 55535 when your urologist makes an incision in the lower abdomen to reach the varicocele.
• 55540 (Excision of varicocele or ligation of spermatic veins for varicocele; with hernia repair). Note: You should report 55540 when the procedure to excise the varicocele also includes a hernia repair.
• 55550 (Laparoscopy, surgical, with ligation of spermatic veins for varicocele). Note: You should report 55550 when your urologist uses a laparoscopic approach to ligate the spermatic veins and excise the varicocele.

Coding tip: There is really no set number of veins to be ligated during a varicocelectomy (code 55530). However, you may consider adding modifier 22 (Increased procedural services) if the extra ligation of veins significantly prolonged the procedure or made the surgery more complicated. Your urologist will be the best one to determine this fact.

Tip 3: Report Correct ICD-10-CM Codes

ICD-10-CM only offers one code for varicocele — I86.1 (Scrotal varices).

If you look under the included diagnoses for I86.1 in the ICD-10-CM manual, you will see this code also includes varicocele.

Tip 4: Don’t Mix up Varicoceles With Hydroceles

Make sure you don’t mix up varicoceles and hydroceles. Although varicoceles and hydroceles may both involve swelling, the cause and affected areas are different.

A hydrocele occurs when fluid collects in the thin sheath surrounding a testicle (known as the tunica vaginalis). The correct diagnosis for a hydrocele of the spermatic cord or testis may be N43.0 (Encysted hydrocele), N43.1 (Infected hydrocele), or N43.3 (Hydrocele, unspecified).

Tip 5: Pay Attention to Medical Necessity

Your urologist will most often perform a varicocele excision to reverse male infertility. A slight increase in intra-scrotal temperature caused by the dilation of the spermatic cord veins often results in infertility, so the excision of the varicocele may restore male fertility.

Payment alert: Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook, cautions that some payers may not reimburse for a varicocelectomy with the associated diagnosis of male infertility (N46.8, Other male infertility). However, the insurer may reimburse for the excision of a varicocele with the diagnosis of scrotal varices (I86.1). So, you should be very careful with your ICD-10-CM codes and the supporting documentation. The medical documentation must clearly support the medical necessity of the varicocelectomy.