How To Use CPT Code 54840

CPT 54840 describes the excision of a spermatocele, with or without epididymectomy. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 54840?

CPT 54840 is used to report the excision of a spermatocele, which is a cyst located between the epididymis and the testis. This procedure may involve the removal of the spermatocele alone or may also include a partial excision of the head of the epididymis. It is important to accurately report this code when documenting the removal of a spermatocele.

2. Official Description

The official description of CPT code 54840 is: ‘Excision of spermatocele, with or without epididymectomy.’

3. Procedure

1. The surgeon administers local anesthesia to the patient.
2. An incision is made in the scrotal wall to expose the testis and epididymis.
3. If necessary, the fluid from the cyst is drained.
4. The spermatocele is excised from its base, and the base is sutured to prevent recurrence.
5. If an epididymectomy is also performed, the epididymis is dissected free from its attachments to the testis.
6. The small blood vessels in the area are cauterized to control bleeding.
7. The epididymis is then removed, and a drain may be placed.
8. The incision is closed by suturing.

4. Qualifying circumstances

CPT 54840 is used when a spermatocele is excised, either with or without an epididymectomy. This procedure is typically performed by a urologist. It is important to note that the code should only be reported for the excision of a spermatocele and not for other procedures or conditions.

5. When to use CPT code 54840

CPT code 54840 should be used when a surgeon performs the excision of a spermatocele, with or without an epididymectomy. It is important to accurately document the procedure and ensure that it aligns with the official description of the code.

6. Documentation requirements

To support a claim for CPT 54840, the following documentation is required:

• Confirmation of the diagnosis of a spermatocele
• Description of the procedure performed, including whether an epididymectomy was also performed
• Date of the procedure
• Details of the surgical approach and technique used
• Any additional procedures or services provided
• Any complications or unusual findings
• Signature of the surgeon performing the procedure

7. Billing guidelines

When billing for CPT 54840, it is important to ensure that the procedure aligns with the official description of the code. It should only be reported for the excision of a spermatocele, with or without an epididymectomy. It is also important to follow any specific billing guidelines provided by payers and to accurately document the procedure to support the claim.

8. Historical information

CPT 54840 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A urologist performs the excision of a spermatocele without an epididymectomy for a patient with a diagnosed spermatocele.
2. A surgeon performs the excision of a spermatocele with an epididymectomy for a patient with a large and recurrent spermatocele.
3. A urologist performs the excision of a spermatocele without an epididymectomy for a patient with a symptomatic spermatocele causing discomfort.
4. A surgeon performs the excision of a spermatocele with an epididymectomy for a patient with a bilateral spermatocele and epididymal involvement.
5. A urologist performs the excision of a spermatocele without an epididymectomy for a patient with a small and asymptomatic spermatocele.
6. A surgeon performs the excision of a spermatocele with an epididymectomy for a patient with a large and painful spermatocele.
7. A urologist performs the excision of a spermatocele without an epididymectomy for a patient with a recurrent spermatocele after a previous excision.
8. A surgeon performs the excision of a spermatocele with an epididymectomy for a patient with a spermatocele causing infertility issues.
9. A urologist performs the excision of a spermatocele without an epididymectomy for a patient with a newly diagnosed spermatocele.
10. A surgeon performs the excision of a spermatocele with an epididymectomy for a patient with a large and symptomatic spermatocele.