Vol. 17 •Issue 10 • Page 13
Coding for the Male Genital System
When more than one procedure is performed, be sure to add modifier 51 to the subsequent codes when appropriate.
Preoperative Diagnosis: Massive bilateral hydroceles
Postoperative Diagnosis: Bilateral hydroceles, massive right spermatocele
Procedure Performed: Bilateral hydrocelectomy with bottle procedure with right spermatocelectomy
Operative Technique: The patient is brought to the operative suite, shaved, prepped and draped in the usual sterile fashion in the supine position following inhalation anesthesia.
A transverse incision is made over the right hemiscrotum, and dissection is carried through the dartos layer with electrocautery. Blunt dissection is used to strip the investing fascia of the hydrocele away from the interior wall of the scrotum. The hydrocele is delivered into the incision. It is opened and drained for approximately 200 cc of straw-colored fluid. It became apparent that a more massive fluid collection is identified at the superior end of the normal-appearing testicle. This then appeared to be a spermatocele. The investing fascia is removed from this and care is taken to strip the tissues from around the spermatocele. It is removed intact and then drained. Approximately 600 cc of turbid fluid is obtained from this. The testicle appeared viable at the end of the procedure. It is returned to the scrotum after noting adequate hemostasis both on the scrotum and the inguinal cord.
We had performed a bottle procedure on the hydrocele sac by inverting the sac and utilizing a 3-0 Vicryl in a running manner to secure it around the cord. The scrotum on this side is closed with 3-0 Vicryl in a running manner through the dartos layer, and the skin is closed with 3-0 Vicryl interrupted sutures. Attention is turned to the left side where a transverse incision is made, and electrocautery is used to dissect the dartos layer. In a similar manner to the right side, the left side hydrocele sac is stripped from the surrounding tissue. The hydrocele is opened and drained again for approximately 300 cc of fluid. A total of 1,150 cc of fluid is drained from both sides of the scrotum. This hydrocele is somewhat larger than the right side and so its tissue is trimmed back with electrocautery. The edges are then reflected back upon the inguinal cord, and a bottle procedure is performed with 3-0 Vicryl in a running fashion. Again, the internal aspect of the left hemiscrotum and inguinal cord itself appeared to be hemostatic as the testicle is returned to its appropriate position. 3-0 Vicryl is used to close the dartos layer in a running fashion and 3-0 chromic is used in an interrupted fashion.
A scrotal supporter and fluffs are applied. The patient tolerated the procedure well. Bilateral inguinal cord blocks are performed, and he is transferred to the recovery room in satisfactory condition.
Preoperative: Massive bilateral hydroceles
603.9 Hydrocele, unspecified
Postoperative: Bilateral hydroceles
603.9 Hydrocele, unspecified
Massive right spermatocele
CPT Code Assignments and Rationale
As the surgeon states in the operative report, a bottle-type procedure was performed on the hydrocele sac. Therefore, you will check the CPT index for the term Bottle Type Procedure, which is followed by code 55060. After reading the complete description, you will see that this is the correct code to assign.
Because the hydrocele excision was performed bilaterally, you will need to assign modifier 50 for the facility and the professional components (two units), which communicates that fact.
In addition to the above procedure, the spermatocele was removed intact from the epididymis without injury. For the excision of the spermatocele, refer to the term Spermatocele in the index. You will see that the term Excision is listed under it, along with code 54840. After reading the complete description, you will see that this is the correct code to assign.
Because the spermatocele was performed only on the right side, you must assign modifier RT to the code for the facility component. This communicates that the procedure was performed only on the right side.
Because this is the second profession-al code assigned for the professional component, you need to add modifier 51, which indicates that multiple procedures were performed.
Facility code assignments look like this:
55060-50 Repair of tunica vaginalis hydrocele (bottle type)
54840-RT Excision of spermatocele with or without epididymectomy
Professional code assignments look similar to the facility code assignments, but not identical, as the modifier used in the second code is different.
55060-50 Repair of tunica vaginalis hydrocele (Bottle type)
54840-51 Excision of spermatocele with or without epididymectomy
Sharon Williamson is a senior health care con-sultant with Medical Learning Inc. (MedLearn®), St. Paul, MN.