Urology Coding Alert

Question: The surgeon created a right/hemiscrotal incision down to the testis. The appendix testis was identified and transected. A spermatocele was also noted and the sac was dissected out under microscopic view. The spermatocele base was ligated and removed, and the scrotum was closed. What codes should I report for this? Do I add a modifier?

Oklahoma Subscriber

Answer: You'll submit two codes for this encounter:

• 54512 (Excision of extraparenchymal lesion of testis) for the appendix testis excision
• 54840 (Excision of spermatocele, with or without epididymectomy) for the spermatocele removal.

CCI edits do not bundle 55840 and 54512. Because of this, no modifier is necessary.

Although 54512 is a very simple procedure but with a higher reimbursement than 54840, a much more complicated procedure, many urologists (especially pediatric urologists) continue to code and bill for both of these services with the appendix testis as the primary procedure and the removal of the spermatocele as the secondary procedure. Most payers will reimburse for both surgical procedures.