Coding Male Genital Procedures

Vol. 18 •Issue 20 • Page 12
Coding Corner

Coding Male Genital Procedures

In the procedure performed, make note of the three modifiers that must be assigned.

Preoperative Diagnosis: Massive bilateral hydroceles

Postoperative Diagnosis: Bilateral hydroceles; massive right spermatocele

Procedure Performed: Bilateral hydrocelectomy with bottle procedure with right spermatocelectomy

Anesthesia: General

Operative Technique: The patient is brought to the operative suite, shaved, prepped and draped in the usual sterile fashion in the supine position following inhalation anesthesia.

A transverse incision is made over the right hemiscrotum, and dissection is carried through the dartos layer with electrocautery. Blunt dissection is used to strip the investing fascia of the hydrocele away from the interior wall of the scrotum. The hydrocele is delivered into the incision and opened and drained for approximately 200 cc of straw-colored fluid. A more massive fluid collection was identified at the superior end of the normal appearing testicle, which appeared to be a spermatocele. We removed the investing fascia from this and took care to strip the tissues from around the spermatocele. It is removed intact and then drained of approximately 600 cc of turbid fluid. The testicle appeared viable at the end of the procedure. It is returned to the scrotum after noting adequate hemostasis, both on the scrotum and the inguinal cord.

We performed a bottle procedure on the hydrocele sac by inverting the sac and utilizing a 3-0 Vicryl in a running manner to secure it around the cord. The scrotum on this side is closed with 3-0 Vicryl in a running manner through the dartos layer, and the skin is closed with 3-0 Vicryl interrupted sutures. Attention is turned to the left side where a transverse incision is made, and electrocautery is used to dissect the dartos layer. In a similar manner as was performed on the right side, the left side hydrocele sac was stripped from the surrounding tissue. The hydrocele is opened and drained again for approximately 300 cc of fluid. A total of 1,150 cc of fluid is drained from both sides of the scrotum. This hydrocele is somewhat larger than the right side and so its tissue is trimmed back with electrocautery. The edges are then reflected back upon the inguinal cord, and a bottle procedure is performed with 3-0 Vicryl in a running fashion. Again, the internal aspect of the left hemiscrotum and inguinal cord itself appeared to be hemostatic as the testicle is returned to its appropriate position. 3-0 Vicryl is used to close the dartos layer in a running fashion, and 3-0 Chromic is used in an interrupted fashion.

A scrotal supporter and fluffs are applied. The patient tolerated the procedure well. Bilateral inguinal cord blocks are performed, and he is transferred to the recovery room in satisfactory condition.


Preoperative Diagnosis: Massive bilateral hydroceles

603.9 Hydrocele, unspecified

Postoperative Diagnoses: Bilateral hydroceles and massive right spermatocele

603.9 Hydrocele, unspecified

608.1 Spermatocele


61.2 Excision of hydrocele (of tunica vaginalis)

63.2 Excision of cyst of epididymis


The surgeon states in the operative report that he performed a “bottle procedure” on the hydrocele sac. When you check in the index under this term, you will see that Bottle Type Procedure is listed and followed by the code 55060. Checking in the Surgery/Male Genital System section of the 2008 CPT manual, you will see the code description is “repair of tunica vaginalis hydrocele (Bottle type).” This is the correct code to assign for the first procedure performed. Because the surgeon performed the hydrocele excision bilaterally, you must assign the modifier 50 (bilateral).

In addition to the Bottle procedure, the surgeon removed the spermatocele intact from the epididymis without injury. Look in the index under the term Spermatocele. The only indented term under this main term is Excision 54840. The code description identifies this code as “excision of spermatocele, with or without epididymectomy.” Because the spermatocele was performed only on the right side, you also need to assign modifier RT (right side) to the facility code. For the professional component, you must add modifier 51 to indicate that a multiple procedure was performed.

Facility component code assignments:

55060-50 Repair of tunica vaginalis hydrocele (Bottle type)

54840-RT Excision of spermatocele with or without epididymectomy

Professional component code assignments:

55060-50 Repair of tunica vaginalis hydrocele (Bottle type)

54840-51 Excision of spermatocele with or without epididymectomy n

Peggy Hapner is manager of the HIM consulting division at Medical Learning Inc. (MedLearn), St. Paul, MN.

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