Sunshine Rose
New
We are new to urology coding. Not sure if we are lacking the right documentation, or if the code for this is just unclear to us. Do you know what CPT we would report for this?
Diagnosis: Hydrocele
Procedure: Spermatic cord injection
The patient was brought to the procedure room and laid in the supine position. The left testis was examined. Bedside ultrasound was used to identify fluid collection and its association with the testis and also identify intended orientation of needle placement and aspiration. 2% lidocaine with epinephrine was used to anesthetize the skin. A 16 French Angiocath was advanced into the hemiscrotum and the hydrocele sac. The needle was withdrawn. A 60 cc syringe was used to aspirate all fluid from the hydrocele sac. When no more fluid could be extracted manual manipulation of the hemiscrotum was used to expel any remaining pockets. A total of 60 milliliters of straw-colored fluid were removed. 5 milliliters of 2% lidocaine were injected into the hemiscrotum via the Angiocath. After allowing that to sit for a minute 6 milliliters of isopropyl alcohol were injected for sclerosis. He tolerated the procedure well. He will return for follow-up based on recurrence of his hydrocele.
Diagnosis: Hydrocele
Procedure: Spermatic cord injection
The patient was brought to the procedure room and laid in the supine position. The left testis was examined. Bedside ultrasound was used to identify fluid collection and its association with the testis and also identify intended orientation of needle placement and aspiration. 2% lidocaine with epinephrine was used to anesthetize the skin. A 16 French Angiocath was advanced into the hemiscrotum and the hydrocele sac. The needle was withdrawn. A 60 cc syringe was used to aspirate all fluid from the hydrocele sac. When no more fluid could be extracted manual manipulation of the hemiscrotum was used to expel any remaining pockets. A total of 60 milliliters of straw-colored fluid were removed. 5 milliliters of 2% lidocaine were injected into the hemiscrotum via the Angiocath. After allowing that to sit for a minute 6 milliliters of isopropyl alcohol were injected for sclerosis. He tolerated the procedure well. He will return for follow-up based on recurrence of his hydrocele.