How To Use CPT Code 55000

CPT 55000 describes the procedure of puncture aspiration of a hydrocele, which involves the removal of fluid from the tunica vaginalis of the scrotum. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 55000?

CPT 55000 can be used to describe the procedure of puncture aspiration of a hydrocele. This involves the removal of fluid from the tunica vaginalis of the scrotum, which is a collection of fluid that can occur due to a defect or irritation in the scrotal membrane. The procedure may also include the injection of medication into the sac to prevent recurrence of the hydrocele.

2. Official Description

The official description of CPT code 55000 is: ‘Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication.’

3. Procedure

  1. The provider prepares the patient for the procedure by cleaning the skin over the hydrocele with an antiseptic.
  2. The provider then punctures the skin and advances a needle into the sac of the hydrocele to collect the fluid.
  3. The provider aspirates, or withdraws, all the fluid content inside the hydrocele.
  4. If necessary, the provider may inject a sclerosing medication into the sac to prevent recurrence of the hydrocele.

4. Qualifying circumstances

CPT 55000 is performed on patients with a hydrocele, which is a collection of fluid around the scrotum. The procedure is typically done when the hydrocele causes discomfort or other symptoms, or if it is large enough to affect the patient’s quality of life. The provider must assess the patient’s condition and determine the need for puncture aspiration of the hydrocele.

5. When to use CPT code 55000

CPT code 55000 should be used when the provider performs a puncture aspiration of a hydrocele, with or without the injection of medication. It is important to note that this code should not be reported if the provider performs a hydrocelectomy or a hernia repair in addition to the puncture aspiration.

6. Documentation requirements

To support a claim for CPT 55000, the provider must document the following information:

  • Patient’s diagnosis of a hydrocele
  • Details of the procedure, including the puncture aspiration and any medication injection
  • Date of the procedure
  • Any complications or adverse reactions
  • Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 55000, ensure that the procedure performed is a puncture aspiration of a hydrocele. It is important to note that this code should not be reported if the provider performs a hydrocelectomy or a hernia repair in addition to the puncture aspiration. If the provider performs only the puncture aspiration, append modifier LT or RT to indicate the left or right side.

8. Historical information

CPT 55000 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

  1. A provider performs a puncture aspiration of a hydrocele on the left side of a patient’s scrotum.
  2. A patient with a large hydrocele undergoes a puncture aspiration procedure to relieve discomfort.
  3. A provider performs a puncture aspiration of a hydrocele and injects a sclerosing medication to prevent recurrence.
  4. A patient with a recurrent hydrocele undergoes a puncture aspiration procedure on the right side of the scrotum.
  5. A provider performs a puncture aspiration of a hydrocele on a pediatric patient with a large hydrocele.
  6. A patient with a symptomatic hydrocele undergoes a puncture aspiration procedure to alleviate symptoms.
  7. A provider performs a puncture aspiration of a hydrocele and documents the procedure in the patient’s medical record.
  8. A patient with a bilateral hydrocele undergoes a puncture aspiration procedure on both sides of the scrotum.
  9. A provider performs a puncture aspiration of a hydrocele and injects a sclerosing medication to prevent recurrence in an adult patient.
  10. A patient with a painful hydrocele undergoes a puncture aspiration procedure for relief.

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