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Common Coding Error: Failing to Appropriately Document Hydrocele Location

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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.

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