How To Use CPT Code 54860

CPT 54860 describes the surgical procedure known as epididymectomy, which involves the removal of the epididymis on one side. This article will provide an overview of CPT code 54860, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 54860?

CPT 54860 is a code used to describe the surgical removal of the epididymis on one side. The epididymis is a highly tubular duct located behind the testis, and it plays a role in the passage of sperm. This procedure is performed by a healthcare provider when there is a need to remove the epididymis due to certain conditions or complications.

2. Official Description

The official description of CPT code 54860 is the following: ‘Epididymectomy; unilateral.’ This code specifically refers to the surgical removal of the epididymis on one side of the scrotum.

3. Procedure

1. During an epididymectomy, the patient is properly prepped and anesthetized.
2. The healthcare provider makes an incision in the skin of the scrotum and testis.
3. The provider explores the testis with the epididymis to identify the area for removal.
4. The epididymis is detached from the testis.
5. The provider cauterizes or ligates the small blood vessels to control bleeding.
6. After the epididymis is freed, it is removed from the scrotum.
7. A drain may be placed, and the incision is closed.
8. This procedure is performed unilaterally, meaning it is only done on one side.

4. Qualifying circumstances

CPT 54860 is used when there is a need to remove the epididymis unilaterally. This procedure may be necessary due to various conditions or complications, such as cysts or chronic problems. It is important to note that bilateral epididymectomy, which involves the removal of the epididymis on both sides, is reported with different CPT codes (54861).

5. When to use CPT code 54860

CPT code 54860 should be used when a healthcare provider performs the surgical removal of the epididymis on one side. It is important to accurately document the procedure and ensure that it is performed unilaterally. If the epididymectomy is performed bilaterally, a different CPT code (54861) should be used.

6. Documentation requirements

When reporting CPT code 54860, the healthcare provider must document the following information:

• Indication for the epididymectomy
• Details of the procedure, including the incision, exploration, detachment, cauterization or ligation of blood vessels, removal of the epididymis, placement of a drain (if applicable), and closure of the incision
• Unilateral nature of the procedure

7. Billing guidelines

When billing for CPT code 54860, it is important to ensure that the procedure is performed unilaterally. If the epididymectomy is performed bilaterally, a different CPT code (54861) should be used. It is also important to follow any specific guidelines provided by the payer or coding guidelines. Ensure accurate documentation to support the claim for reimbursement.

8. Historical information

CPT code 54860 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 healthcare provider performs an epididymectomy on one side to remove a cyst from the epididymis.
2. During surgery, the provider discovers a chronic problem with the epididymis and decides to perform a unilateral epididymectomy.
3. A patient presents with a large spermatocele on one side, and the provider performs an epididymectomy to remove it.
4. After an examination, the healthcare provider determines that a hydrocele on one side requires surgical intervention, leading to a unilateral epididymectomy.
5. A patient is diagnosed with a tunica vaginalis cyst on one side, and the provider performs an epididymectomy to remove it.