Urology Coding Alert

Question: Our patient was to have a hydrocelectomy. After the patient was asleep, the urologist examined the area - one testicle felt quite firm, which raised suspicions of carcinoma. The urologist incised the groin instead of the scrotum and proceeded to explore the groin area. He sent a testis biopsy, which came back negative. Excessive fibrosis made it impossible to establish a plane between the tunica vaginalis and the tunica albuginea of the testicle. The hydrocele sac was extremely scarred. The urologist was able to dissect 50 percent of the sac, open it and excise the visible hydrocele sac in the area. How should I code for all this work?

Ohio Subscriber

Answer: Report CPT Code 54530-52 (Orchiectomy, radical, for tumor; inguinal approach; reduced services) for the inguinal approach the urologist used to explore the groin.

Since the testicle was examined but not removed, append modifier -52 to 54530 to indicate reduced services.

Because the urologist didn't remove the testicle, the biopsy is considered a separate procedure. Use code 54505-59 (Biopsy of testis, incisional [separate procedure]; distinct procedural service) for the biopsy. Modifier -59 breaks CPT 54505 from the 54530 bundle and also allows payment for the biopsy.

Finally, report CPT 55040 (Excision of hydrocele; unilateral) for the hydrocelectomy.

Self-defense: As with all cases when you break a bundle with modifier -59, be sure to include ample documentation with your claim to back up your assertion that the services were distinct and necessary.