A hydrocele is a common condition seen in men. It occurs when fluid accumulates within the tunica vaginalis in the scrotum, whether congenital (communicating) or acquired. Hydrocele surgery is indicated when a patient has a symptomatic hydrocele.

When scheduling or performing surgery on a hydrocele, many providers inaccurately state that they will be doing a “hydrocelectomy.” By definition, a word the suffix “-ectomy” implies excision of a structure, yet not all hydrocele surgeries involve the excision of the tunica vaginalis. Coding for hydrocele procedures is based upon the type of surgery performed: aspiration, excisional procedures (accurately called a “hydrocelectomy”) and nonexcisional (hydrocele repair) procedures, which do not involve excision of tissue. The applicable codes include:

CPT code 55000 Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication

CPT code 55000 should be chosen if a hydrocele is aspirated, such as using a needle. Aspiration of a hydrocele is most commonly performed in an office setting using a local anesthetic. As per the code description, CPT code 55000 would include the work of injecting a medication such as a sclerosing agent to help reduce the risk of recurrence. If a sclerosing agent is injected, the agent itself can be billed separately if done within an office setting.

CPT codes 55040 Excision of hydrocele; unilateral and 55041 Excision of hydrocele; bilateral

As described above, these 2 codes describe an excisional procedure approach to hydrocele surgery, also knows as a “hydrocelectomy.” This approach includes excising tunica vaginalis tissue. Excision and removal of tissue is often accompanied by over-sewing the edges of the hydrocele sac. CPT code 55040 should be chosen if a hydrocelectomy is performed unilaterally and CPT code 55041 chosen if a hydrocelectomy is performed bilaterally.

CPT code 55060 Repair of tunica vaginalis hydrocele (Bottle type)

Unlike the excisional procedure, CPT code 55060 should be chosen for a nonexcisional hydrocele repair. The most common example of a nonexcisional repair is when the hydrocele sac is opened and sewn behind the testicle, which some may call a Jaboulet repair whereas others refer to it as a bottle repair. Another example of a nonexcisional repair is a Lord’s technique of repair. While a Lord’s repair and other nonexcisional procedures are not specifically noted in the descriptor of CPT code 55060, it would be most accurate to use this code for any procedure that does not involve excision of a hydrocele sac. Note that there is no code for performing this procedure bilaterally, so if repair is performed bilaterally then the appropriate bilateral modifier would be used based upon the insurer. If a hydrocelectomy (CPT code 55040) is performed on one side and a hydrocele repair (CPT code 55060) on the contralateral side, both should be coded and the appropriate modifier appended.

CPT code 55500 Excision of hydrocele of spermatic cord, unilateral (separate procedure)

From time to time a hydrocele may be found on the spermatic cord and not on the testicle. CPT code 55500 would be used to code the repair of a hydrocele found up on the spermatic cord.

Other codes which may be applicable to coding for hydrocele surgeries:

CPT code 54840 Excision of spermatocele, with or without epididymectomy

From time to time a patient may present with both a hydrocele and a spermatocele. At other times, a spermatocele may be discovered upon scrotal exploration. In these cases, both an excision of a spermatocele and a hydrocele surgery may be performed. The National Correct Coding Initiative (NCCI) edits bundles 54840 with 55040, meaning if both procedures are performed on the same side through the same incision then only one of the procedure(s) can be coded. Since 55040 is the higher value procedure, that should be reported. If the procedures were performed on contralateral sides or through different incisions/approaches then both codes should be reported with the appropriate modifier.

CPT codes 49491-49501 and 49495-49525: initial inguinal hernia repair codes

There are unique codes for repair of initial inguinal hernia based upon the age of the patient: preterm infants (younger than 37 weeks of gestation at birth) performed from birth up to 50 weeks post-conception age, full-term infants younger than 6 months (or preterm infants >50 weeks post-conception age), age 6 months to 5 years and age 5 years or older. The codes for initial inguinal hernia repair for preterm infants, younger than 6 months and age 6 months to 5 years include the descriptor “with or without hydrocelectomy” and therefore a concomitant hydrocele repair performed through the same incision (which is often the case) cannot be coded separately. In these age groups, a hydrocele repair can be coded separately if performed through a separate incision or on the contralateral side, with the use of the appropriate modifier. The “with or without hydrocelectomy” language is not part of the descriptor for initial inguinal hernia repairs for age 5 years or older and can be billed separately.