Question: My urologist did a right inguinal exploration for a mass and a right testicular open biopsy. He excised a palpable mass from 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?
Answer: Review your urologist’s documentation and the operative report. Then consider which of the following CPT codes best describes the inguinal procedure:
Use diagnosis code 215.6 (Benign neoplasm, pelvis [groin, inguinal region]).
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 either 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: