Urology Coding Alert

Question: How should I code for a scrotal exploration with removal of hematoma?

Alabama Subscriber

Answer: You should report CPT 54700 (Incision and drainage of epididymis, testis, and/or scrotal space [e.g., abscess or hematoma]) for the drainage of the hematoma. Payers will include the scrotal exploration with this CPT Code. The Correct Coding Initiative (CCI), however, does not bundle these two procedures with an edit, so if the scrotal exploration was a significant part of the procedure after drainage of the hematoma, then you could report both procedures separately. For example, if the urologist explored the scrotal contents for bleeding or other pathology, you could report both the exploration and the drainage.

Coding breakdown: First, report 55110 (Scrotal exploration) for the extensive exploration. Then, use 54700 for the drainage of the hematoma. Append modifier 51 (Multiple procedures) to the latter CPT code to show that the urologist performed multiple procedures.

Diagnosis wrap-up: For this procedure, the diagnoses may include 608.83 (Vascular disorders), which includes scrotum "hematoma, non-traumatic" or 922.4 (Contusion of trunk; genital organs), which indicates scrotum hematoma traumatic.