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CPT 55041: Bilateral Scrotal Fluid Removal

CPT code 55041 represents a bilateral surgical procedure to remove fluid-filled sacs from the scrotum, typically performed to relieve pain or discomfort from hydroceles or similar conditions. This code is relevant nationally as it captures a common urologic surgical service that affects outpatient surgical volumes, anesthesia utilization, and post-operative care pathways. Payers commonly involved in coverage and reimbursement discussions for this service include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.

Readers will find a concise overview of clinical context and coding intent, plus operational and policy-relevant content such as typical sites of service, common billing considerations, and what to expect in payer coverage patterns. The publication also outlines available benchmarks where present and notes when input data are not available. The aim is to equip coding professionals, surgical practices, and health plan analysts with a clear, national-level reference on how CPT code 55041 is used, where it is typically performed, and the primary payers that underwrite care for this service.

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Billing Code Overview

CPT code 55041 describes the surgical removal of fluid-filled sacs from both sides of the scrotum (the pouch that contains the testes) to relieve pain or discomfort. This procedure targets bilateral scrotal or testicular fluid collections and is performed to address symptomatic hydroceles or similar fluid accumulations.

Service type: Surgical procedure (bilateral scrotal fluid drainage/excision)
Typical site of service: Ambulatory surgery center or hospital outpatient department, depending on patient complexity and anesthesia needs

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CPT 55041: Bilateral Scrotal Fluid Removal

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Billing Code Overview

Service type: Surgical procedure (bilateral scrotal fluid drainage/excision)
Typical site of service: Ambulatory surgery center or hospital outpatient department, depending on patient complexity and anesthesia needs

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult male presenting with unilateral or bilateral scrotal swelling and discomfort due to hydroceles. The patient often reports progressive enlargement of the scrotal sac, a sensation of heaviness, and intermittent aching pain that worsens with activity or prolonged standing. Physical exam reveals a non-tender, fluctuant, transilluminating mass surrounding the testicle(s). Ultrasound of the scrotum is performed to confirm fluid collection around the testicle, exclude spermatocele, testicular torsion, epididymitis, or intratesticular mass, and to evaluate testicular blood flow.

The clinical workflow includes preoperative assessment and informed consent, surgical scheduling for an outpatient or ambulatory procedure, preoperative anesthesia evaluation (local, regional, or general anesthesia), intraoperative excision/drainage of the hydrocele sac with ligation or plication as indicated, and postoperative recovery with brief observation. Typical follow-up occurs in clinic within 1–2 weeks to assess wound healing, edema resolution, and confirm symptom relief.

Coding Specifications

Modifier	Description	When to Use
`50`	Bilateral procedure	Use when both left and right hydroceles are surgically treated during the same operative session.
`51`	Multiple procedures	Use when additional distinct procedures are performed at the same operative session in addition to the hydrocelectomy.
`52`	Reduced services	Use when the procedure is partially reduced or not completed as originally planned.
`53`	Discontinued procedure	Use when the hydrocelectomy is started but discontinued due to extenuating circumstances.
`59`	Distinct procedural service	Use to indicate a procedure is distinct/separate from another procedure performed on the same day when bundling rules might apply.
`62`	Two surgeons	Use when two surgeons work together as primary surgeons performing distinct portions of the procedure.
`66`	Surgical team	Use when a surgical team is required for the operative management.
`76`	Repeat procedure by same physician	Use if the same physician performs the hydrocelectomy again later the same day (uncommon).
`77`	Repeat procedure by another physician	Use if another physician repeats the hydrocelectomy later the same day.
`78`	Unplanned return to OR for related procedure by same physician	Use if the patient returns to the OR related to the initial hydrocelectomy during the postoperative global period.
`79`	Unrelated procedure or service by same physician during global period	Use when an unrelated procedure is performed during the global period of the hydrocelectomy.
`LT`	Left side	Use to designate procedures performed on the left testis/scrotum when laterality reporting is required.
`RT`	Right side	Use to designate procedures performed on the right testis/scrotum when laterality reporting is required.
`AS`	Ambulatory surgical center	Use to indicate the service was provided in an ambulatory surgical center setting.

Taxonomy Code	Specialty	Notes
2080P0800X	Urology	Urologists most commonly perform hydrocelectomy and manage male genital surgery.
207P00000X	General Surgery	General surgeons in some settings perform elective scrotal surgery including hydrocelectomy.
208H00000X	Pediatric Urology	Pediatric urologists perform hydrocelectomy in pediatric patients when indicated.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`N43.3`	Hydrocele, other and unspecified	Direct indication for hydrocelectomy when symptomatic or large.
`N43.1`	Spermatocele	May be diagnosed on ultrasound and can coexist; requires differentiation from hydrocele; sometimes addressed surgically.
`N45.1`	Epididymitis	Inflammatory causes of scrotal swelling and pain that must be excluded prior to elective hydrocelectomy.
`N48.4`	Hematospermia	Not a direct indication but may be part of genitourinary bleeding workup in differential diagnosis of scrotal/testicular conditions.
`R22.1`	Localized swelling, mass and lump, trunk	General code for localized swelling if more specific scrotal code not used; less preferred.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`54150`	Circumcision, surgical; newborn	Not directly related but may be performed in the same patient population for separate indications; listed as a separate genital surgical procedure.
`54520`	Orchidectomy, simple (removal of testis)	Performed when testicular pathology requires orchiectomy rather than hydrocelectomy; alternative definitive procedure for testicular disease.
`53200`	Not applicable	Data not available in the input.
`99213`	Office or other outpatient visit for evaluation and management	Commonly used for preoperative evaluation and postoperative follow-up visits related to hydrocelectomy.
`99140`	Not applicable	Data not available in the input.

CPT 55040: Excision of Fluid-Filled Sac of Scrotum, Unilateral

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

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Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Modifier	Description	When to Use
`50`	Bilateral procedure	Use when both left and right hydroceles are surgically treated during the same operative session.
`51`	Multiple procedures	Use when additional distinct procedures are performed at the same operative session in addition to the hydrocelectomy.
`52`	Reduced services	Use when the procedure is partially reduced or not completed as originally planned.
`53`	Discontinued procedure	Use when the hydrocelectomy is started but discontinued due to extenuating circumstances.
`59`	Distinct procedural service	Use to indicate a procedure is distinct/separate from another procedure performed on the same day when bundling rules might apply.
`62`	Two surgeons	Use when two surgeons work together as primary surgeons performing distinct portions of the procedure.
`66`	Surgical team	Use when a surgical team is required for the operative management.
`76`	Repeat procedure by same physician	Use if the same physician performs the hydrocelectomy again later the same day (uncommon).
`77`	Repeat procedure by another physician	Use if another physician repeats the hydrocelectomy later the same day.
`78`	Unplanned return to OR for related procedure by same physician	Use if the patient returns to the OR related to the initial hydrocelectomy during the postoperative global period.
`79`	Unrelated procedure or service by same physician during global period	Use when an unrelated procedure is performed during the global period of the hydrocelectomy.
`LT`	Left side	Use to designate procedures performed on the left testis/scrotum when laterality reporting is required.
`RT`	Right side	Use to designate procedures performed on the right testis/scrotum when laterality reporting is required.
`AS`	Ambulatory surgical center	Use to indicate the service was provided in an ambulatory surgical center setting.

Taxonomy Code	Specialty	Notes
2080P0800X	Urology	Urologists most commonly perform hydrocelectomy and manage male genital surgery.
207P00000X	General Surgery	General surgeons in some settings perform elective scrotal surgery including hydrocelectomy.
208H00000X	Pediatric Urology	Pediatric urologists perform hydrocelectomy in pediatric patients when indicated.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`N43.3`	Hydrocele, other and unspecified	Direct indication for hydrocelectomy when symptomatic or large.
`N43.1`	Spermatocele	May be diagnosed on ultrasound and can coexist; requires differentiation from hydrocele; sometimes addressed surgically.
`N45.1`	Epididymitis	Inflammatory causes of scrotal swelling and pain that must be excluded prior to elective hydrocelectomy.
`N48.4`	Hematospermia	Not a direct indication but may be part of genitourinary bleeding workup in differential diagnosis of scrotal/testicular conditions.
`R22.1`	Localized swelling, mass and lump, trunk	General code for localized swelling if more specific scrotal code not used; less preferred.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`54150`	Circumcision, surgical; newborn	Not directly related but may be performed in the same patient population for separate indications; listed as a separate genital surgical procedure.
`54520`	Orchidectomy, simple (removal of testis)	Performed when testicular pathology requires orchiectomy rather than hydrocelectomy; alternative definitive procedure for testicular disease.
`53200`	Not applicable	Data not available in the input.
`99213`	Office or other outpatient visit for evaluation and management	Commonly used for preoperative evaluation and postoperative follow-up visits related to hydrocelectomy.
`99140`	Not applicable	Data not available in the input.

CPT 55040: Excision of Fluid-Filled Sac of Scrotum, Unilateral

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Jul 29, 2026.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Jul 29, 2026.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

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CPT 55041: Bilateral Scrotal Fluid Removal

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Billing Code Overview

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CPT 55041: Bilateral Scrotal Fluid Removal

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Billing Code Overview

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References

Clinical & Coding Specifications

Clinical Context

Coding Specifications

Related Diagnoses

Related CPT Codes

Related Codes

References