How To Use CPT Code 55040

CPT 55040 describes the excision of a hydrocele, a fluid-filled sac in the scrotal area, on one side of the scrotum. 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 55040?

CPT 55040 is used to describe the excision of a hydrocele, which is a fluid collection within a sac in the scrotal area. This procedure is performed on one side of the scrotum to relieve pain or discomfort caused by the hydrocele. It involves the removal of the fluid-filled sac and the closure of the remaining tissues with sutures.

2. Official Description

The official description of CPT code 55040 is: ‘Excision of hydrocele; unilateral.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An incision is made in the scrotum to access the hydrocele.
3. The provider locates the hydrocele and separates it from the surrounding structures.
4. The hydrocele is excised, and the fluid is drained from the scrotum.
5. The remaining tissues are closed with sutures in layers.

4. Qualifying circumstances

CPT 55040 is performed on patients with a hydrocele, which is a fluid collection within the scrotal area. The procedure is indicated when the hydrocele causes pain or discomfort. It is important to note that CPT 55040 is specific to unilateral excision of a hydrocele, meaning it is performed on one side of the scrotum. If the provider performs excision on both sides, CPT code 55041 should be reported.

5. When to use CPT code 55040

CPT code 55040 should be used when the provider performs a unilateral excision of a hydrocele. It is appropriate when the hydrocele on one side of the scrotum requires removal to alleviate pain or discomfort. If the provider performs excision on both sides, CPT code 55041 should be reported instead.

6. Documentation requirements

To support a claim for CPT 55040, the provider must document the following information:

• Patient’s diagnosis of a hydrocele
• Details of the procedure, including the incision, excision of the hydrocele, and closure of tissues
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 55040, ensure that the procedure is performed on one side of the scrotum, as it is specific to unilateral excision of a hydrocele. If the provider performs excision on both sides, CPT code 55041 should be reported instead. It is important to follow the guidelines provided by the payer and use the appropriate modifiers if necessary.

8. Historical information

CPT 55040 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 patient presents with a painful hydrocele on the right side of the scrotum. The provider performs a unilateral excision of the hydrocele using CPT code 55040.
2. A patient complains of discomfort caused by a hydrocele on the left side of the scrotum. The provider performs a unilateral excision of the hydrocele using CPT code 55040.
3. A patient with a large hydrocele on the right side of the scrotum seeks medical attention. The provider performs a unilateral excision of the hydrocele using CPT code 55040.
4. A patient is diagnosed with a hydrocele on the left side of the scrotum and experiences pain. The provider performs a unilateral excision of the hydrocele using CPT code 55040.
5. A patient presents with a hydrocele on the right side of the scrotum, causing discomfort during physical activities. The provider performs a unilateral excision of the hydrocele using CPT code 55040.
6. A patient complains of pain and swelling caused by a hydrocele on the left side of the scrotum. The provider performs a unilateral excision of the hydrocele using CPT code 55040.
7. A patient with a hydrocele on the right side of the scrotum seeks surgical intervention due to persistent discomfort. The provider performs a unilateral excision of the hydrocele using CPT code 55040.
8. A patient is diagnosed with a hydrocele on the left side of the scrotum and experiences pain during physical activities. The provider performs a unilateral excision of the hydrocele using CPT code 55040.
9. A patient presents with a large hydrocele on the right side of the scrotum, causing significant discomfort. The provider performs a unilateral excision of the hydrocele using CPT code 55040.
10. A patient complains of pain and swelling caused by a hydrocele on the left side of the scrotum. The provider performs a unilateral excision of the hydrocele using CPT code 55040.