Urology Coding Alert

Question: I am new to urology coding, and I’m not sure if we are lacking the right documentation or if the correct code is just unclear to us. Can you help me figure out the appropriate CPT^® code for a spermatic cord injection? The diagnosis is testicular pain. According to the medical documentation, the patient was brought to the procedure room and laid in the supine position. My urologist examined the left testis, and he noted tenderness at the left epididymal head. My urologist isolated the spermatic cord and used a three-finger technique at the external ring. My urologist then injected 7 cc of 2% lidocaine with 40 mg of Kenalog into the cord after aspiration to be sure the needle was not in a blood vessel. The patient tolerated the procedure well. He was instructed to pay close attention to the presence or absence of pain over the next couple of hours and days.

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Answer: Since no specific nerves for injection/treatment were mentioned in the medical documentation, you should report 64450 (Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch) for this clinical scenario.

Don’t miss: This code represents a unilateral service, meaning your provider performs the procedure on one side. If your provider performs this procedure bilaterally, you should report 64450 once with modifier 50 (Bilateral procedure) appended. Or you could report 64450 twice — once with modifier RT (Right side) and again with modifier LT (Left side), depending upon each payer’s preference.