Urology Coding Alert

Question: My urologist performed a repeat vasectomy nine months after the patient's first vasectomy because the first one failed. I'm not sure how I should code it. Would I need a modifier to indicate that it was a second procedure?

Idaho Subscriber

Answer: You should report CPT 55250 (Vasectomy, unilateral or bilateral [separate procedure], including postoperative semen examination[s]) without any modifiers. Because the global surgical period for 55250 is usually 90 days, the second procedure isn't affected by the global period of the first vasectomy performed nine months earlier.
 
You might think you need to append modifier 76 (Repeat procedure by same physician), but that's not the case in this example.
 
For a primary diagnosis, report V25.2 (Encounter for contraceptive management; sterilization). Report 998.89 (Other specified complications of procedures, not elsewhere classified; other specified complications) as a secondary diagnosis to represent the previously failed vasectomy.