(2022) Hydrocelectomy CPT Code Description, Guidelines, Reimbursement, Modifiers & Examples

Hydrocelectomy CPT Code(s) 55040 or 55041 bills for service when the physician performs surgical removal of hydrocele unilaterally or performed on each testis. The physician performs surgery to remove fluid from around one or both testicles.

Hydrocelectomy CPT Code Description

A hydrocele is a sac of fluid in the tunica vaginalis or along the spermatic cord. The physician treats a hydrocele by eliminating it. 

The physician injects local anesthesia and sterilizes the target using techniques. They make an incision in the scrotum or the inguinal area. 

The physician keeps the hydrocele intact when detached from the testis and the other structures. The sac is opened, drained, and partially excised, leaving a tissue remnant. The remaining tissue is swung back behind the epididymis and the spermatic cord and closed by suturing the edges together. 

The testis attaches to the scrotum’s inside, which comprises three sutures to prevent later torsion or twisting of the testis. A rubber drain may y left eft in the scrotum, and the incision closed in layers by suturing. The hydrocele is on one side in 55040. Hydrocelectomy CPT Code 55041 bills when the physician treats both sides for hydrocele.

Hydrocele does not cause pain, and the predominant symptom is scrotum swelling. The swelling size of hydrocele may vary in the morning and evening.

The following are the types of hydrocele:

Nonc-ommunicating hydroceles appear when the body does not adequately absorb the fluid after the sac closes. It can take 12 months to absorb the liquid. 

Communicating hydroceles arises when the sac fails to close the way and allows the fluid in and out.

Nuck’s hydroceles appear in persons without testicles. It may occur in the pelvic lining and cause painful scrotum swelling. 

Hydrocelectomy CPT Code 55040 bills for service when the physician performs unilateral surgical removal of hydrocele.

Hydrocelectomy CPT Code 55041 bills for service when the physician performs bilateral surgical removal of hydrocele.

Hydrocelectomy CPT Code Reimbursement 

A maximum of one unit can be a bill on the same service date of Hydrocelectomy CPT Code(s) 55040-55041. In contrast, the Two units allow documentation supporting the service’s medical necessity. 

The cost and RUVS of CPT 55040 are $370.80 and 10.71486 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 55040 are $370.80 and 10.71486 when performed in the non-facility. 

The cost and RUVS of CPT 55041 are $558.58 and 16.14095 when performed in the facility. In contrast, the reimbursement and RUVS of CPT 55041 are $558.58 and 16.14095 when performed in the non-facility.

Hydrocelectomy CPT Code Modifiers

The following are the list modifiers applicable with Hydrocelectomy CPT Code 55040 and 55041 :   

22, 23, 47, 51, 52, 53, 54, 55, 56, 58, 59, 62, 63, 76, 77, 78, 79, 80, 81 82, 99, , AS, CC, CR, ET, EY, GA, GC, GK, GR, GU, GY, GZ, KX, Q5, Q6, QJ, SG, TC, XR, XP, XU, XS, AI, AQ, AR.     

Modifier 47 applies to CPT 55040 and 55041 when the surgeon administers general or regional anesthesia to the patient. It is not appropriate to report modifier 47 with anesthesia procedures.  

Modifier 76 is appropriate with CPT 55040 and 55041 when a similar service performs by the Same Physician on the same service date.   

Modifier 54 is applicable with CPT 55040 and 55041 when the physician provides surgical care only. In contrast, Modifiers 55 and 56 attach to CPT 55040 and 55041 when the physician performs post-management and preoperative care only.   

Modifier 76 is applicable with Hydrocelectomy CPT Code(s) 55040 and 55041 when a similar service performs by a different Physician on the same service date.   

Modifier 59 is applicable with CPT 55040 and 55041 when a Distinct service performs by the physician and bundled with another procedure on the same date.     

 Modifier X {E, P, S, U} is applicable instead of Modifier 59 with CPT 55040 and 55041 when service bills to Medicare insurance. It divides the modifier into four parts for further specification of the procedure.   

Modifier 53 will be reported with CPT 55040 and 55041 if an unsuccessful attempt for Hydrocelectomy makes due to unavoidable circumstances like allergic reactions to the substance.   

Modifier 22 applies to CPT 55040 and 55041 when services perform longer than usual and take extra resources during the procedure.   

Modifier 23 is applicable with Hydrocelectomy CPT Code(s) 55040 and 55041 when general or local anesthesia administers by the physician and routinely does not require during the procedure.   

Modifier 52 applies when the physician does not complete the Hydrocelectomy service and terminates due to unavoidable circumstances.   

If physicians believe that Medicare will deny such service, reporting with a GA modifier is appropriate. The beneficiary must sign an Advance Beneficiary Notification (ABN), and CPT 55040 and 55041 must apply the GA modifier to that service.

Hydrocelectomy CPT Code Billing Guidelines

Documentation should support the medical necessity of service. It reflects that service is medically necessary and appropriate.  

The following are ICD 10 Payable Dx codes when Hydrocelectomy CPT Code 55040 or 55041 bills:

N43.0, N43.1, N43.2, N43.3, P83.5.

If the physician performs a Repair hernia with hydrocelectomy (49495-49501) in conjunction with CPT 55040, 0r 55041, It is appropriate to report separately.

If the physician performs puncture aspiration of hydrocele, it is appropriate to report with 55000 instead of 55040 or 55041. 

If the physician performs an excision of a spermatic cord hydrocele, it is appropriate to report with 55000 instead of 55040 or 55041. 

Suppose any evaluation and management service performs in conjunction with CPT code 55040 or 55041 on the same day, one day before surgery, or in the postoperative period for an unrelated condition. In that case, it is appropriate to report E/M codes 99201-99499 with modifier 25.

Suppose the physician performs any service related to CPT 55040 or 55041 in the postoperative period. Hydrocelectomy CPT Code 55040 or 55041 has 90 days global period. It is appropriate to report separately. 

Hydrocelectomy CPT Code Examples

The following is the example when Hydrocelectomy CPT Code 55040 and 55041 bills:

Example 1

PREOPERATIVE DIAGNOSIS: Bilateral hydroceles. 

POSTOPERATIVE DIAGNOSIS: Bilateral hydroceles. 

PROCEDURE: Bilateral scrotal hydro-celectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given. 

ESTIMATED BLOOD LOSS: Less than six mL. 

FLUIDS RECEIVED: 700 mL

TUBES AND DRAINS: A 0.18-inch Penrose drains x 3. 

INDICATIONS FOR OPERATION: 

A Twenty-year-old boy presents to the surgeon with large appearing Hydroceles. 

DESCRIPTION OF OPERATION: 

The patient takes to the operating room. The physician obtains the surgical consent and operative site and verifies patient identification.

The physician administered anesthesia to the patient and shaved, prepped, and then sterilely prepped and draped. 

A scrotal incision makes in the right hemiscrotum with a 15-blade knife and further extended with electrocautery. IV antibiotics give to the patient. Ancef 1 g given. 

Electrocautery was used for hemostasis. Once we got to the hydrocele sac, we opened and delivered the testis and drained clear fluid.

There was moderate scarring on the testis itself from the tunica vaginalis. It was then wrapped around the back and sutured with a 4-0 chromic running suture in a Lord maneuver.

The physician inserts a drain at the base of the scrotum. He places the testis back into the scrotum in the proper orientation.

He repeats the procedure on the left, which also had a cord hydrocele, addressed and closed with the Lord maneuver. This testis was also average but had moderate scarring on the tunica vaginalis.

The physician utilizes a similar drain. The skin sutures with a running interlocking suture of 3-0 Vicryl and the gutters suture to place with 3-0 Vicryl.

The surgeon put the testis back into the scrotum in a standardized manner, and the local wound installation and wound block. 

The physician placed using 30 mL of 0.5% Marcaine without epinephrine. IV Toradol gives at the end of the procedure. 

The physician placed bacitracin dressing, ABD dressing, and jockstrap. After that, the patient transfers to the recovery room once the condition becomes stable.

Example 2

PREOPERATIVE DIAGNOSIS: Unilateral hydroceles. 

POSTOPERATIVE DIAGNOSIS: Unilateral hydroceles. 

PROCEDURE: Right scrotal hydro-celectomies, 0.5% Marcaine wound instillation, 30 mL given. 

ESTIMATED BLOOD LOSS: Less than six mL. 

FLUIDS RECEIVED: 200 mL

TUBES AND DRAINS: A 0.18-inch Penrose drains x 2. 

INDICATIONS FOR OPERATION: 

A Twenty-Five-year-old boy presents to the surgeon with large appearing Hydroceles. 

DESCRIPTION OF OPERATION: 

The patient takes to the operating room. The physician obtains the surgical consent and operative site and verifies patient identification. The physician administered anesthesia to the patient and shaved, prepped, and then sterilely prepped and draped. 

A scrotal incision makes in the right hemiscrotum with a 15-blade knife and further extended with electrocautery. IV antibiotics give to the patient. Ancef 1 g given. 

Electrocautery was used for hemostasis. Once we got to the hydrocele sac, we opened and delivered the testis and drained clear fluid. There was moderate scarring on the testis itself from the tunica vaginalis. It was then wrapped around the back and sutured with a 4-0 chromic running suture in a Lord maneuver.

This testis was also average but had moderate scarring on the tunica vaginalis. The physician inserts a drain at the base of the scrotum. He places the testis back into the scrotum in the proper orientation.

The physician placed bacitracin dressing, ABD dressing, and jockstrap. After that, the patient transfers to the recovery room once the condition becomes stable.