Tanesha Posted Mon 16th of December, 2019 10:40:14 AM
Should this be an unlisted for the hydrocele procedure. The doctor originally stated hydrocelectomy, but this appears wasn't done per the body of the report. Op excerpt: I then turned my attention distally. I compressed the hemiscrotum and no fluid was decompressed, indicating either a small hole or a flap valve mechanism. I therefore pushed the hydrocele up into the suprapubic area. I gently dissected the tissues down with the DeBakeys, just separating the fibers until I got down to the tunica vaginalis and hydrocele sac. I actually just ended up separating it with my DeBakeys and opening up the hydrocele sac. Meticulous hemostasis was obtained with the bipolar. Careful attention was paid to avoid any critical structures. This decompressed the right hemiscrotum completely. The testicle was then brought back into its anatomic position. The vessel loop was removed. Both testicles are sitting nicely in the scrotum and there is full decompression.
SuperCoder Answered Tue 17th of December, 2019 09:40:45 AM
As per the limited information provided above, I will provide you different scenarios to bill for the above procedure, you may further match it with the complete operative report.
For open hernia repair we will bill 49500 (Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible). This is a unilateral procedure, if performed bilaterally we will append modifier 50.
For hydrocelectomy, if performed, we will bill CPT 55040 (Excision of hydrocele; unilateral) and if performed bilaterally 55041 (Excision of hydrocele; bilateral).
However, as per NCCI edit we cannot bill 49500 and 55040 together if performed on the same side. hydrocelectomy will bundle with hernia repair code.
Also, if inguinal hernia is performed on one side and hydrocelectomy on other side, then we can bill both the codes together with modifier 59 (Distinct Procedural Service).
Feel free to ask for any further query.
Tanesha Posted Tue 17th of December, 2019 12:00:53 PM
Thank you, but the only other documentation was the hernia repair which I didn't include. I'm only questioning the hydrocele portion. Did you see a hydrocelectomy in the provided excerpt? I didn't necessarily see this.
SuperCoder Answered Wed 18th of December, 2019 04:44:31 AM
Hydrocelectomy involves incision in the scrotum, placement of tube into incision to drain fluid, hydrocele sac removal, and finally closure of stitches.
I do not see all this documentation in the above provided report.
NOTE: CPT code 49500 will include hydrocelectomy if performed. there is no need to bill cpt for hydrocelectomy seperately.