Coding Surgical Procedures in Male Fertility


The code for the epididymal biopsy is –54865 –exploration of the epididymis with or without biopsy. This is an open procedure and can be used for unilateral or bilateral, and has a 90-day global period. Surgical assistants are not allowed or paid. And this code, the 54865, bundles the needle biopsy of the testicle, the 54500, performed at the same time that you would do the 54865. The asterisk after that codes reminds us that if we do the exploration and biopsy of the epididymis and then do a needle biopsy of the testicle at the same time, we can bill for both unbundling the 54500 with modifier -59. This does not hold and we cannot unbundle an incisional biopsy, the 54505 when performed with the 54865.

On the other hand, the code 54800 is the code for a needle biopsy of the epididymis. When it comes to surgical procedures to improve male fertility, there's the code 55530 which is an excision of a varicocele or ligation of the spermatic veins. And this is an inguinal approach. We also have an abdominal approach with the code 55535. This abdominal approach is rarely used at the present time. And we do have a code 55540 for a varicocelectomy with a hernia repair. The general surgeon repairs the inguinal hernia and he calls the urologist in to help or to perform the varicocelectomy. Probably the most accurate coding would be to bill these two surgeons as co-surgeons or both as primary surgeons using modifier -62. The general surgeon would bill the code 55540 modifier -62. And his diagnosis would indicate what part of that procedure he did. The diagnosis is inguinal hernia, unilateral with no obstruction or gangrene, 550.90. The urologist also bills as a co-surgeon using the code again, same code, 55540 with modifier -62. His diagnosis indicates what particular part of the 55540 he did. And that's the varicocele, 456.4. Now, in this case, remember that co-surgeons will be paid only with added supporting documentation to establish the medical necessity of two surgeons for this procedure, the 55540.  

Now, this is a second option of how to bill this particular clinical scenario. And this is probably what is billed more often. The general surgeon repairs an inguinal hernia and he bills the code for repair of inguinal hernia, 49505 with the same inguinal hernia diagnosis unilateral non-obstructing and non-gangrenous, 550.90. The urologist performs the varicocelectomy. And he'll bill the 55530 and his diagnosis is going to be varicocele 456.4.

Now, for non-Medicare carriers, each surgeon may bill as an assistant to each other so that the general surgeon is going to bill for the hernia repair, 49505 and he may also bill for the assistant at the varicocelectomy, 55530. The urologist will bill for the varicocelectomy, 55530, and for the assistant for the hernia repair, 49505 modifier -80. Now, the general surgeon, unfortunately, may not be paid for the assisted for the varicocelectomy for many carriers feel that an assistant is not required for a varicocelectomy. On the other side, the urologist will certainly be paid for the assistant at the hernia repair because a hernia repair certainly is – an assistant – and a hernia repair is certainly required.

 

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