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Nancy Posted Tue 19th of December, 2017 09:33:19 AM
Would 55000 and 76998 be correct? With ultrasound guidance, the epididymis is evaluated, and there are multiple cysts in the epididymis, 3 prominent cysts, the largest being 3 cm. Grossly the echotexture of the testicles is normal bilaterally and there is no evidence of mass or nodularity. Skin is prepped with chlorhexidine and then 2% lidocaine injected subcutaneous, then a 20-gauge IV catheter was used to aspirate 3 of the cysts. Clear straw-colored fluid obtained, compression for hemostasis and Neosporin.
SuperCoder Answered Wed 20th of December, 2017 02:11:12 AM

Hi,

As per the provided documentation, aspiration of epididymal cyst was performed. CPT code 55000 is specific to Puncture aspiration of hydrocele. CPT code for Hydrocele should not be billed for aspiration of epididymal cyst. There is a more appropriate CPT code that should be billed.

You should report code 10021 (Fine needle aspiration; without imaging guidance) or 10022 ( with imaging guidance), depending on whether imaging guidance was used to perform the aspiration. 

Please find below SuperCoder newsletter link for more understanding:

https://www.supercoder.com/coding-newsletters/my-urology-coding-alert/reader-question-dont-assume-it-was-aspiration-article

 

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