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Question: The urologist performed a surgical procedure where a low inguinal incision was made at the top of the left hemiscrotum. The surgeon then dissected through Scarpa’s fascia until reaching the external ring. The cord structures were identified, and the left testis was brought out. A notably hard cord was palpated, which softened at the internal ring and extended distally to the epididymis. The tube was ligated at both ends and the hardened section was removed. There was an observation of inflammatory discharge from the tube. The area was then cleaned with an irrigation process and Kenalog was injected into the proximal and distal sections of the vas deferens. Following this, the tunica vaginalis was opened and the testis was examined, revealing a healthy blood supply. Given this, the decision was made by the urologist to try and preserve the testis, which was then repositioned back into the left hemiscrotum. The external ring was reconstructed using interrupted 3-0 chromic sutures, and Scarpa’s fascia was similarly reapproximated with 3-0 chromic sutures. The incision was closed in two layers using 4-0 Monocryl sutures. The urologist then injected the entire area with Marcaine 0.5 percent plain and completed skin closure using Dermabond. The diagnosis and reason for surgery was inflamed epididymis and cord. The pathology result was vas deferens calcification and inflammation, but was negative for malignancy. Is code 55250 correct for this procedure?

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Answer: “No, for the procedure you described above, code 55250 [Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)] would not be appropriate,” says John Piaskowski CPC-I, CPMA, CUC, CRC, CGSC, CGIC, CCC, CIRCC, CCVTC, COSC, specialty medicine auditor at Capital Health in Trenton, New Jersey. “Instead, you should look to 54830 [Excision of local lesion of epididymis] for this procedure based on the excision of the calcified segment of tube, the epididymis, followed by suture repair,” Piaskowski adds.

The injection into the vans deferens, which is only slightly farther away from the testes than the epididymis, might be additionally coded as 55899 (Unlisted procedure, male genital system). This is an unusual service to perform during an epididymis treatment, but is meant to reduce the inflammation also seen in the surgical field.

To increase your chances of reimbursement, be sure you submit clear and complete documentation supporting the medical necessity of the procedure.

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