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Scenario Week of May 18, 2011:
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The patient was brought to the operating room, placed under general endotracheal anesthesia. The groin area was shaved, prepped, and adequately draped; 1% Xylocaine with Marcaine was administered. An oblique incision starting from the pubic tubercle toward the iliac spine, carried for 4 cm was then carried through the subcutaneous tissue. The fascia was divided; the cord was isolated; a Penrose drain was placed around it. Exploration around the cord in the internal ring did not reveal evidence of any indirect or direct hernia. As a result of this finding, a left spermatocelectomy was done.

An incision was made over the spermatocele, and the spermatocele sac was exposed and excised, taking care not to injure the cord. Bleeders were cauterized. Skin was closed with subcuticular sutures of 2.0 chromic catgut. Dermabond was applied to the skin. The external oblique was closed with a continuous suture of 2-0 Vicryl making sure not to incorporate any nerves. The subcutaneous tissue was closed with a continuous suture of 4-0 Vicryl and reinforced with Steri-strips. Dressing was applied. The patient left the operating room in good condition.

CPT Code and Rationale:

54840 Excision of spermatocele, with or without epididymectomy

Originally, the surgeon indicated the procedure was to repair a left inguinal hernia; however, after exploring the groin area, it was determined that a hernia was not present. In this case, the service was not performed upon determination that a hernia was not present and the service would be considered an exploration of the groin.

Subsequently, a left spermatocelectomy was performed and is represented by CPT code 54840 Excision of spermatocele, with or without epididymectomy. In the CPT index, under the main term, spermatocele, excision, the coder is directed to see code 58540.

CCI guidelines in Chapter VI, Section E, state that “an exploratory laparotomy (CPT code 49000) is not separately reportable with an open abdominal procedure.” Although this guideline specifically states abdomen, the concept applies to other similar open procedures. In addition, the CCI guidelines in chapter 1 state that exploration of an incisional site is always incidental to a definitive procedure.

ICD-9-CM Code and Rationale:

608.1 Spermatocele

In volume 2, the alphabetic index, the main term spermatocele is listed with code 608.1. There is a subterm for congenital spermatocele. Documentation does not specify the spermatocele as congenital; therefore, code 608.1 is confirmed in the tabular listing. No further digits are required.

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