You Be the Coder:
Residual Hydrocele and Foreign Body Granuloma After Vasectomy
Published on Thu May 15, 2014
Question: My urologist performed a left hydrocelectomy with excision of right sperm granuloma and extraction of a vasectomy clip on the left side. I am not sure of the proper coding. For example, should I use an unlisted code for the extraction?
Maine Subscriber
Answer: For this procedure, first report 55520 (Excision of lesion of spermatic cord [separate procedure]) for the removal of the sperm granuloma. You would attach diagnosis code 608.89 (Other specified disorders of male genital organs).
Then, use 55040 (Excision of hydrocele; unilateral) for the excision of the hydrocele. The diagnosis code to attach to this procedure is 603.0 (Encysted hydrocele).
You may also bill the removal of the vasectomy clip, a foreign body in the scrotum, with code 55120 (Removal of foreign body in scrotum). The attached diagnostic code should be 729.6 (Residual foreign body in soft tissue).
