Urology Coding Alert

Question: A 32-year-old presents to our urology clinic with concerns about intermittent movement of their left testicle. They report that the testicle is usually located within the scrotum but occasionally moves upward into the groin area during exercise, cold weather, or periods of stress. When this occurs, the patient notices a sensation of fullness in the inguinal region but denies having significant pain, swelling, urinary symptoms, or a history of trauma.

On physical examination, both testicles are initially present within the scrotum. During the exam, the left testicle is observed to retract into the inguinal canal after stimulation of the cremaster muscle. The physician is able to gently guide the testicle back into the scrotum, where it remains temporarily. No masses, tenderness, or signs of hernia are identified.

The urologist determines that the patient has a retractile testicle and discusses monitoring for any changes in testicular position, discomfort, or fertility concerns. Surgical intervention is not recommended at this time because the testicle can be manually returned to the scrotum and does not remain permanently undescended. Is the appropriate CPT^® code 54640?

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Answer: No, since the practitioner did not perform a procedure on the patient, it would be inappropriate to report 54640 (Orchiopexy, inguinal or scrotal approach).

Because they are choosing to monitor the condition at this point, you would choose an appropriate evaluation and management (E/M) code and assign ICD-10-CM code Q55.22 (Retractile testis) to the claim.

Don’t miss: If the patient eventually moved forward with fixation (orchiopexy) of an intra-abdominal testicle, then it would be appropriate to report 54640 or 54650 (Orchiopexy, abdominal approach, for intra-abdominal testis (eg, Fowler-Stephens)), depending on the procedure performed. Also, if the provider performs an orchiopexy of an intra-abdominal testis using a laparoscopic approach, you will report 54692 (Laparoscopy, surgical; orchiopexy for intra-abdominal testis).

Also, be sure to add the modifier LT (Left side) for laterality to the applicable fixation CPT^® code. However, for procedures performed on both testes, you’ll report the appropriate orchiopexy procedure code appended with modifier 50 (Bilateral procedure).

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC