Urology Coding Alert

Question: How should I report a bilateral spermato-celectomy for a Medicare patient?

Indiana Subscriber

Answer: According to the Medicare Physician Fee Schedule Database (MPFSDB), spermatocelectomy code 54840 (Excision of spermatocele, with or without epididymectomy) cannot be appended with the bilateral modifier -50 (Bilateral procedure).

 The reasoning: The fee for a spermatocelectomy has been valued to account for the occasional time when this procedure is performed bilaterally. But when the physician has difficulty performing a bilateral procedure, such as for unusually large spermatoceles, or increased fibrosis from previous recurrent epididymitis, you may be entitled to increased reimbursement for increased work.

 To account for the additional work and time spent performing the bilateral spermatocelectomy, append modifier -22 (Unusual procedural services) to 54840 when submitting a claim to Medicare to ensure that the claim will be reviewed, and submit the operative report and the physician's explanatory note. You should also append modifier -50, which will indicate to the carrier that the reason the procedure deserves special review is that the surgeon performed it bilaterally: 54840-22-50. With suitable documentation, you may receive increased reimbursement from Medicare.

 For private payers, check their local medical review policies to determine the carrier's position on coding bilateral procedures and find out if it abides by the MPFSDB billing rules. If not, you will most likely be required to report the procedure using either modifier -50 or the modifiers -LT (Left side) and -RT (Right side) or a combination of both, such as 54840-LT and 54840-50 on separate lines.