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:
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.