Urology Coding Alert

Question: What CPT^® code would I use when the urologist performs an excision of a scrotal varicose vein? The vein was located on the scrotal skin, not the spermatic cord.

Wyoming Subscriber

Answer: CPT^® 2018 does not include a specific code for excision of a varicose vein of the scrotal skin. Because of this, your best option is to report 55899 (Unlisted procedure, male genital system). Remember that when you report a procedure with an “unlisted” code, include a cover letter explaining the reason for choosing the unlisted code instead of a defined, active code. Also include the operative notes or other relevant documentation to strengthen the claim and to avoid a possible denial. Your payers will consider claims with unlisted procedure codes on a case by case basis, and they will determine payment based on the documentation you provide.

Benchmark your unlisted code to CPT^® codes 11420 to 11426 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia …) based on the size of the vein removed.

Also note: Clinically, the term for varicose vein of the scrotal skin points to varicocele, which is an enlargement of veins within the scrotum. If the procedure performed was excision of a varicocele, the most appropriate code will be 55530 (Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure)).