Common Coding Error: Failing to Appropriately Document Hydrocele Location
According to Lolita M. Jones, RHIA, CCS, independent coding consultant, the CPT Codebook includes two categories of CPT codes for a hydrocele excision. If the hydrocele is removed from the tunica vaginalis, or the serous covering of the testis, coders should use CPT 55040 (for a unilateral procedure) or CPT 55041 (for a bilateral procedure). If the hydrocele is removed from the spermatic cord, coders should use CPT 55500. "Sometimes the physician isn't clear about where the hydrocele was removed from, and [the coders] just default to the spermatic cord code," she says. "The location really should be documented."
She says this issue generally arises from poor physician documentation or poor coder understanding of documentation. Either reason is a problem. If the physician does not indicate the location of the excised hydrocele, the coder should query the physician to make sure the correct code is used. If coders are repeatedly ignoring or misunderstanding the physician's indication of the hydrocele's location, they may need to brush up on their knowledge of the procedure.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
© Copyright ASC COMMUNICATIONS 2012. Interested in LINKING to or REPRINTING this content? View our policies by clicking here.
To receive the latest hospital and health system business and legal news and analysis from Becker's Hospital Review, sign-up for the free Becker's Hospital Review E-weekly by clicking here.
New from Becker's ASC Review
CareCloud Reports Sales Growth in 1Q 2014Read Now
- Randy Oostra, Michael Sanborn, and Dr. Michael Schatzlein to Speak at Becker's Hospital Meeting
- 6 Questions to Help Identify the Best Candidates for Hire
- Medical Device Industry leader to Know: Guntmar Eisen of Paradigm Spine
- Unique Methods of Payment: Opportunities for ASCs?
- ASC M&A Activity: 4 Big Trends for 2014 From HealthCare Appraisers