1. Procedure and CPT® Code Selection:
The patient underwent a bilateral excisional vasectomy for sterilization.
CPT® Code 55250 represents a bilateral vasectomy with excision, which includes postoperative care. The code already implies a bilateral procedure, so it is not necessary to add the -50 modifier for bilateral designation.
2. Diagnosis and ICD-10-CM Code Selection:
ICD-10-CM Code Z30.2 is used for encounter for sterilization and is the correct code to report for a planned sterilization procedure such as a vasectomy.
Code Z30.012 is specific to encounter for sterilization of a female patient, which does not apply in this male patient scenario.
3. Rationale for Excluding Other Options:
55250-50 (in options C and D) is unnecessary because the CPT® code 55250 inherently covers a bilateral vasectomy, and applying the -50 modifier is redundant.
Z30.012 (options B and D) is incorrect as it pertains to female sterilization procedures, not male.
4. AAPC and CPT® Coding Guidelines:
According to AAPC guidelines, 55250 is reported without a bilateral modifier, as the procedure inherently covers both sides. Additionally, Z30.2 is the correct ICD-10-CM code for male sterilization procedures.
Thus, the correct answer based on CPT® and ICD-10-CM guidelines is A. 55250, Z30.2.
