© Copyright 2025 American Medical Association. All rights reserved.
Epididymectomy is a surgical procedure that involves the removal of the epididymis, which is a coiled tube located at the back of the testis responsible for storing and maturing sperm. This procedure is typically performed on one side of the scrotum, hence the term "unilateral." The patient is positioned supine, meaning they lie flat on their back, and the surgical area, including the penis and scrotum, is prepared and draped to maintain a sterile environment. A transverse incision is made in the skin of the hemiscrotum, allowing access to the underlying structures. The surgeon employs both sharp and blunt dissection techniques to carefully separate the testis, epididymis, and vas deferens from surrounding tissues, ensuring that these structures are freed and brought into the operative field for further manipulation. If the patient has previously undergone a vasectomy, the dissection will continue above the vasectomy site to ensure complete removal of the epididymis. In cases where no prior vasectomy has been performed, the vas deferens may be cut and ligated with absorbable sutures. The procedure continues with dissection towards the vaso-epididymal junction, where the epididymis is detached from the testis. The surgeon ligates the epididymal artery if encountered and removes the entire specimen intact. After the removal, the surgical site is irrigated, and any bleeding is controlled before closing the incision in layers. This procedure is coded as CPT® Code 54860 for unilateral epididymectomy, while CPT® Code 54861 is used for bilateral procedures.
© Copyright 2025 Coding Ahead. All rights reserved.
The indications for performing a unilateral epididymectomy may include the following conditions:
The procedure for a unilateral epididymectomy involves several key steps, which are detailed as follows:
Post-procedure care following a unilateral epididymectomy typically involves monitoring for any signs of complications, such as infection or excessive bleeding. Patients may be advised to rest and avoid strenuous activities for a specified period to promote healing. Pain management may be provided as needed, and follow-up appointments are usually scheduled to assess recovery and address any concerns. It is important for patients to adhere to their surgeon's post-operative instructions to ensure optimal recovery.
| Short Descr | REMOVAL OF EPIDIDYMIS | Medium Descr | EPIDIDYMECTOMY UNILATERAL | Long Descr | Epididymectomy; unilateral | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 118 - Other OR therapeutic procedures, male genital |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.