Urology Coding Alert

  Reviewed on May 27, 2015 Question: My urologist did a right inguinal exploration for a mass and a right testicular open biopsy. He excised a palpable massfrom the groin, and the frozen section showed no evidence of malignancy. I’m not sure what codes to use. The only inguinal exploration code I found is for an undescended testis. What codes would you suggest for this procedure?   Ohio Subscriber   Answer: Review your urologist’s documentation and the operative report. Then consider which of the following CPT® codes best describes the inguinal procedure: 27047(Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; less than 3 cm) or 27043 (...3 cm or greater) if the exploration was in the inguinalsubcutaneous tissue, with excision of a subcutaneous mass, or 27048 (… subfascial [e.g., intramuscular]; less than 5 cm) or 27045 (... 5 cm or greater) if the exploration is deeper within the inguinal canal, with excision of a mass in the inguinal canal. Use diagnosis code 215.6 (Benign neoplasm, pelvis [groin, inguinal region]) For ICD-10, report D21.5 (Benign neoplasm of connective and other soft tissue of pelvis).   Note: Code 54505 (Biopsy of testis, incisional [separate procedure]) is for the open testicular biopsy, and the Correct Coding Initiative (CCI) does not bundle it into any of the above inguinal procedures. So you can report both procedures if your urologist performs both in the same session. Exploration of the groin is an integral part of 27047 and 27048 and is therefore included in these procedures. Although there is no specific CPT® code for groin exploration, an unlisted-procedure code, such as 53899 (Unlisted procedure, urinary system), would be inappropriate, and under these circumstances you should not report it in addition to the above.   Exception: You should report an inguinal exploration for an undescended testicle (54550, Exploration for undescended testis ...) followed by an orchiectomy (54520, Orchiectomy, simple ... scrotal or inguinal approach) for an atrophic testicle in the inguinal canal in the following way:   54550 (Exploration for undescended testis [inguinal or scrotal area]) for the inguinal exploration with 752.51 (Undescended testis) or for ICD-10, report Q53.-- as the diagnosis 54520-51 (Orchiectomy; multiple procedures) for the orchiectomy with 608.3 (Atrophy of testis) or for ICD-10, report N50.0 as the diagnosis.