Basics of hydrocelectomy CPT code

Hydrocelectomy is surgery that is done to remove or repair a hydrocele. A hydrocele is a fluid-filled sac surrounding a testicle that causes swelling in the scrotum (the pouch that holds the testicles). Hydroceles are common in newborn males. Hydroceles can be scary because you can see them and because they are in a sensitive part of the body.

In Medical coding also, we have CPT code for hydrocelectomy procedures. Most of the time coders are difficulty in coding hydrocelectomy  cpt code because of not clear documentation of procedure performed. Today we will try to learn more about it.  

We have learnt different coding surgery procedures like knee arthroscopy, hip arthroplasty, lysis of adhesions, shoulder repair etc. This excision procedure is quite similar to these exams.

Generally hydrocele does not cause any pain. But, if there is pain in the scrotum, pain relievers can be used to treat this symptom of hydroceles or even physician can opt for surgery if needed. So, hydrocelectomy  can be said as the last and best option for treatment for hydrocele.  

Read also: Best coding tips for Pelvic Ultrasound CPT code 76856 and 76830

We have two categories of procedure codes for hydrocele excision. The two CPT codes are based of the excision of hydrocele from specific location.  We have separate code for unilateral and bilateral CPT code for hyrocelectomy. 

Description of CPT code 55040 & 55041

The physician excises a hydrocele, also referred to as hydrocelectomy. The tunica vaginalis is the serous sheath covering the testis and epididymis that consists of an outer parietal and inner visceral layer. A hydrocele is a collection of fluid between the parietal and visceral layers. The scrotum is examined and the location of the fluid collection determined. An incision is made in the groin for children or in the scrotum for adults. The parietal layer of the tunica vaginalis is incised and the fluid drained. The wall of the hydrocele sac is closed or partially excised to prevent recurrence. Overlying tissues are closed in layers.

CPT code 55040 is used for a unilateral procedure and CPT code 55041 is used for a bilateral hydrocele.

If If the hydrocele is removed from the tunica vaginalis, or the serous covering of the testis, coders should use CPT 55040 (for a unilateral procedure) or CPT 55041 (for a bilateral procedure).

55040 Excision of hydrocele (unilateral)

55041 Excision of hydrocele (Bilateral)

If the hydrocele is removed from the spermatic cord, medical coders should report CPT code 55500.

55500 Excision of hydrocele of spermatic cord, unilateral (separate procedure)

The location should be clearly documented for coding the correct CPT code. We should not assume when the location for hydrocele removal is not documented by the physician.

ICD-10 supporting CPT code CPT code 55040, 55041 & 55500

References:

http://www.beckersasc.com/asc-coding-billing-and-collections/common-coding-error-failing-to-appropriately-document-hydrocele-location.html