Urology Coding Alert

Question: My urologist made a transverse inguinal incision with a 15-blade and dissection was carried down through Scarpa’s down to the external oblique fascia. My urologist opened the external oblique fascia in the direction of its fibers to the external ring. Care was taken to avoid injury to the ilioinguinal nerve, which was carefully swept off the spermatic cord. My urologist then developed the spermatic cord and encircled it with a Penrose drain. The mass and testis were then delivered into the inguinal incision. The mass was firm and separate from the testis. My urologist was able to dissect the mass off the spermatic cord. There were some attachments that appeared to be more vascular in nature, so my urologist clamped these with Kelly clamps and divided and tied them. My urologist then passed the specimen off the field for intraoperative frozen pathology. My urologist compressed the remnants of the tissue by the Kelly clamps. My urologist doubly tied them with 2-0 silk ties and used 2-0 Prolene sutures as a stick tie as well. Pathology indicated they did not feel that this was a malignant tumor and was leaning more toward a benign tumor. However, further workup was needed. My urologist elected to leave the testis and placed it back into its correct anatomical position. The final diagnosis was angiofibroma. Which CPT^® code should I report on my claim?

AAPC Forum Subscriber

Answer: You should report 55520 (Excision of lesion of spermatic cord (separate procedure)) for this procedure.

Don’t miss: According to the descriptor for 55520, a physician can perform this procedure separately, but you should not report it when performed along with a related procedure such as at the same anatomic area or through the same incision, orifice, or surgical approach. If your provider performs this procedure with an unrelated procedure, you should append modifier 59 (Distinct procedural service) to 55520.