How To Use CPT Code 55110

CPT 55110 describes the procedure of scrotal exploration, which involves the inspection of the scrotum and its contents for any abnormalities or defects. This article will provide an overview of CPT code 55110, 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 55110?

CPT 55110 is a code used to describe the procedure of scrotal exploration. It involves the examination of the scrotum, which is the sac that contains the testes or testicles, and its contents to identify any abnormalities or defects. This procedure is typically performed by a healthcare provider to assess the condition of the scrotum and its structures.

2. Official Description

The official description of CPT code 55110 is: ‘Scrotal exploration: The provider inspects the scrotum, the pouch that contains the testes, or testicles, and its contents for any defect or abnormality, such as twisting and or entrapment of the vascular supply to a testicle.’

3. Procedure

1. During the scrotal exploration procedure, the healthcare provider examines the scrotum to assess its condition and identify any abnormalities or defects.
2. An incision is made in the scrotum to gain access to its contents.
3. The provider inspects the structures within the scrotum, including the testes or testicles, for any signs of twisting or entrapment of the vascular supply.
4. If necessary, a drain may be placed to allow for the drainage of fluid.
5. The incision in the scrotum is then closed using sutures.

4. Qualifying circumstances

CPT code 55110 is typically used when a scrotal exploration procedure is performed to assess the scrotum and its contents for defects or abnormalities. This procedure may be necessary in cases where there is a suspected twisting or entrapment of the vascular supply to a testicle. It is important to note that this code represents a unilateral service, meaning it is performed on only one side of the scrotum. If the procedure is performed bilaterally, modifiers such as 50, RT, or LT may need to be appended to indicate the side or whether it is a bilateral procedure.

5. When to use CPT code 55110

CPT code 55110 should be used when a healthcare provider performs a scrotal exploration procedure to inspect the scrotum and its contents for any abnormalities or defects. This code is appropriate when there is a need to assess the scrotum for twisting or entrapment of the vascular supply to a testicle. It is important to review the documentation and indications for the procedure to ensure accurate reporting of CPT code 55110.

6. Documentation requirements

To support a claim for CPT code 55110, the healthcare provider must document the following information:

• Patient’s diagnosis or reason for the scrotal exploration procedure
• Details of the procedure, including the incision made in the scrotum and any findings or abnormalities observed
• Any additional procedures performed during the scrotal exploration, such as the placement of a drain
• Details of the closure of the incision, including the use of sutures
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 55110, it is important to ensure that the procedure meets the criteria outlined in the official description. The scrotal exploration procedure should be performed by a qualified healthcare provider and involve the inspection of the scrotum and its contents for defects or abnormalities. 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 code 55110 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 performing a scrotal exploration procedure to assess a patient with suspected testicular torsion.
2. A general surgeon conducting a scrotal exploration to evaluate a patient with a suspected hydrocele.
3. A pediatric surgeon performing a scrotal exploration to assess a child with undescended testicles.
4. An emergency medicine physician conducting a scrotal exploration to evaluate a patient with acute scrotal pain.
5. A urologist performing a scrotal exploration to assess a patient with a suspected testicular tumor.
6. A general surgeon conducting a scrotal exploration to evaluate a patient with a suspected inguinal hernia.
7. A pediatric surgeon performing a scrotal exploration to assess a child with a suspected testicular torsion.
8. An emergency medicine physician conducting a scrotal exploration to evaluate a patient with scrotal trauma.
9. A urologist performing a scrotal exploration to assess a patient with a suspected epididymitis.
10. A general surgeon conducting a scrotal exploration to evaluate a patient with a suspected spermatocele.