Hydrocelectomy CPT Coding Guideline

What is Scrotum ? 

The scrotum is a protective, muscular pouch of skin hanging behind the penis. It is divided into two different sacs by a central ridge called the perineal raphe, with each side primarily housing a testis.Its main role is to control the temperature of the testes, keeping them slightly cooler than normal body temperature, which is necessary for sperm production. It also protects the testes. 

The scrotum has three main structure inside it :

1.Testis 

2.Epididymis- Situated at the head of tach testicle and it store the sperm. 

3.Spermatic Cord 

What is Testis ? 

Testis are oval shape gland found in the sac of scrotum.

It produce sperm cells.

It secreted male sex hormone testosterone. 

What is Epididymis?

The epididymis is a long, coiled tube located at the back of each testis.

Functions:

1. It is a reservoir for sperm after they are produced in the testis.

2. Allows sperm to mature, so they can move properly

3. Transports sperm to the vas deferens during ejaculation.

What is Spermatic cord?

It is a cord-like structure in the male reproductive system that runs from the deep inguinal ring in the abdomen down into the scrotum.

Spermatic cord contain vas deferens.

What is Tunica vaginalis?

The tunica vaginalis is a thin sac (membrane) that surrounds each testicle inside the scrotum. 

It contains a small amount of fluid that helps the testicle move smoothly inside the scrotum. It reduces friction. 

Hydrocelectomy : CPT coding guideline

What is Hydrocele? 

Hydro means water, Cele means Swelling.

So, hydrocele is the accumulation of fluid inside the scrotum that cause swelling.

Surgical Treatment of Hydrocele 

1.Aspiration of Tunica Vaginalis: 55000 

2.Hydrocelectomy/Excision of Hydrocele- 

a.Canal of Nuck- 55899 

b.Spermatic Cord-55500 

c.Other/unspecified- 55040,55041 

3.Repair (Bottle type of Tunica Vaginalis Hydrocele) :55060

Difference between CPT 55040 VS 55500

Scrotum or Inguinal Incision : 55040, 55041 

• Incision over the scrotum or over the groin 

• Dissection along testis and other structure 

• Tunica Vaginalis entered 

• Hydrocele sac around the testicle 

• The sac is opened, drained and excised 

For Spermatic Approach :55500 

• Scrotum or Inguinal Incision 

• Incision over the scrotum or over the groin 

• Dissection along spermatic cord 

• The sac is opened, drained and excise al the way to internal inguinal ring.