Urology Coding Alert

Keep your biopsy options straight as well.

An orchiectomy is surgery to remove one or both testicles. A urologist usually performs orchiectomy because of testicular cancer but can also recommend the surgery because of testicular damage due to injury or infection or a part of prostate cancer treatment.

When coding for these procedures, you need to start with verifying two important details: the surgeon's approach, a simple or radical approach and whether the procedure was a partial or total removal of the testicle.

Understand the Procedure Terminology

Coders can sometimes be confused by the different terms used for orchiectomy. When you see the word "radical" in the operative report, it means the urologist removed the complete testis and the inguinal spermatic cord at the level of the internal inguinal ring via an inguinal approach. You would code this procedure using code 54530, orchiectomy, radical, for tumor, inguinal approach.

Distinguishing between "simple" and "partial" orchiectomy can also trip up coders.

The lowdown: Simple orchiectomy involves the removal of one or both testicles at the distal spermatic cord, usually through an anterior trans-scrotal approach. You would code this procedure using code 54520 (Orchiectomy, simple [including subcapsular], with or without testicular prosthesis, scrotal or inguinal approach).

A partial orchiectomy preserves the testicle for a patient who has a tumor that can be removed without removing the total or complete testicle. A partial orchiectomy is technically more sophisticated than a total orchiectomy. For a partial orchiectomy you'll report code 54522 (Orchiectomy, partial).

Caution:  Don't be tempted to report a partial orchiectomy by using 54520 with modifier 52 (Reduced service) appended. That was your only option for years until CPT® introduced 54522, but now 54522 is the more accurate choice.

Even when you're reporting a radical orchiectomy, you have two choices based on the surgeon's approach:

• 54530 (Orchiectomy, radical, for tumor; inguinal approach) for an inguinal (through the groin) approach
• 54535 (Orchiectomy, radical, for tumor; with abdominal exploration) including an intra-abdominal examination.

Bottom line: "A simple orchiectomy is usually performed for nonmalignant testicular disease such as an ischemic testicle after prolonged testicular torsion or chronic inflammation, while a radical orchiectomy is usually performed for malignant disease of the testicle such as a testicular cancer," explains Michael A. Ferragamo, MD, FACS, clinical assistant professor at the State University of New York in Stony Brook.

If you see in the documentation that the urologist performed the orchiectomy laparoscopically, you should report CPT^® code 54690 (Laparoscopy, surgical; orchiectomy).

Remember to Bill the Biopsy

The urologist will often biopsy a suspected tumor before performing an orchiectomy, but will handle that step in different ways, depending on the situation.

Example 1: A urologist who diagnoses testicular cancer preoperatively by clinical examination, sonography (76870,  Ultrasound, scrotum and contents), and testicular markers (blood test) will proceed to surgery without a biopsy, removing the testicle using an inguinal approach and billing 54530. On the rare occasions that this procedure is performed bilaterally, bill 54530 with modifier 50 (Bilateral procedure).

Example 2: If the urologist questions whether a malignant tumor exists, and there are normal blood markers, but an area of calcification is palpable in the testicle. The urologist performs a biopsy after clamping the cord and walling off the surgical field as above. The urologist sends the specimen to the lab for a stat, frozen, analysis. If the biopsy is positive, the urologist proceeds to a radical orchiectomy, billing 54530. The urologist should also bill for the biopsy. The needle biopsy (54500, Biopsy of testis, needle [separate procedure]) is not bundled into 54530. Therefore, codes 54530 and 54500 apply for a radical orchiectomy and a needle biopsy. An incisional biopsy (54505, Biopsy of testis, incisional [separate procedure]) is bundled into 54530. Therefore, code 54505-59 (Distinct procedural service) in addition to 54530 for a radical orchiectomy and an incisional testicular biopsy. The physician should also be paid for the biopsy as well as the orchiectomy because the biopsy was necessary to determine treatment.

Take note: The reimbursement for needle biopsy (54500) is higher than that for incisional biopsy when performed in the office, yet an incisional biopsy (54505) requires more work. However, needle biopsies are rarely performed, and incisional biopsies are rarely performed in the office. Because 54505 is rarely performed in the office, there is no place-of-service differential. Performed in the hospital, 54505 pays much more than 54500.

Needle Biopsy But No Orchiectomy

A diagnosis of testicular cancer is usually made clinically because the tumor feels hard and certain tumor markers are elevated. An orchiectomy is performed based on this clinical judgment. But when a urologist only suspects testicular cancer, he or she must biopsy the tumor before deciding on treatment. For this reason, a biopsy performed during a surgical session may proceed to a total orchiectomy if the biopsy is positive. The coding dilemma lies in how to bill for the surgical work if the biopsy is negative and no orchiectomy is performed.

If the in-surgery biopsy is benign, the urologist replaces the testicle into the scrotum and closes the wound. Bill 54530 with modifier 52 (Reduced services) to indicate a lesser procedure: an inguinal approach and mobilization of the testicle without orchiectomy. Also report the biopsy with 54500, (Biopsy of testis, needle)-51 (Multiple procedures) or 54505 (Biopsy of testis, incisional)-59-51.

Exploration Does Not Merit Separate Coding

Some urologists think they should be paid for the "exploration" involved in dissecting and looking for the tumor. Any surgical procedure code, however, includes the exploration, as well as the viewing, the examination, and the preparation of the operative site.

In addition, do not use 54550 (Exploration for undescended testis [inguinal or scrotal area]) for the dissection, because that code is defined as an exploration for an undescended testicle, Ferragamo says. Code 54550 is not appropriate because this patient did not have an undescended testicle.

In another exploration-type scenario, the urologist sometimes finds a benign epidermoid cyst (D29.21, Benign testis tumor), that must be removed. He or she removes only the cyst and repairs the testicle. Report only 54522. In this case a biopsy code should not be billed as the excised specimen will be examined pathologically and serve as a biopsy specimen.