How To Use CPT Code 54861

CPT 54861 describes the surgical procedure known as epididymectomy, which involves the removal of the epididymis. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 54861?

CPT 54861 is used to describe the surgical removal of the epididymis. This procedure is performed bilaterally, meaning it is done on both sides of the patient.

2. Official Description

The official description of CPT code 54861 is: ‘Epididymectomy; bilateral.’

3. Procedure

1. During the epididymectomy procedure, the provider makes an incision in the scrotum and testis.
2. They then explore the testis with the epididymis and detach the epididymis from the testis.
3. The provider cauterizes or ligates the small blood vessels to control bleeding.
4. After freeing and removing the epididymis, a drain is placed, and the incision is closed.
5. This procedure is performed bilaterally, meaning it is done on both sides.

4. Qualifying circumstances

CPT 54861 is performed on patients who require the surgical removal of the epididymis. This procedure is typically done when there are cysts on the epididymis or chronic problems that necessitate its removal. It is important to note that when an epididymectomy is performed with a spermatocelectomy, the epididymectomy is not separately payable. CPT code 54861 should be used for bilateral procedures.

5. When to use CPT code 54861

CPT code 54861 should be used when the provider performs a bilateral epididymectomy, meaning the procedure is done on both sides of the patient. It should not be reported separately when performed with a spermatocelectomy.

6. Documentation requirements

To support a claim for CPT 54861, the 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, and closure of the incision
• Confirmation that the procedure was performed bilaterally
• Any complications or additional findings during the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 54861, ensure that the procedure is performed bilaterally. It should not be reported separately when performed with a spermatocelectomy. It is important to follow the specific guidelines provided by the payer to ensure accurate billing and reimbursement.

8. Historical information

CPT 54861 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 patient undergoes a bilateral epididymectomy to remove cysts on both sides of the epididymis.
2. A provider performs a bilateral epididymectomy on a patient with chronic problems in the epididymis.
3. An individual requires a bilateral epididymectomy due to complications from a previous spermatocelectomy.
4. A patient undergoes a bilateral epididymectomy as part of their treatment for an epididymal tumor.
5. A provider performs a bilateral epididymectomy on a patient with recurrent spermatoceles.