Billing code 54865: Epididymal explorationMedicare rate & RVUs in Washington
Urologists report operative exploration of the epididymis when suspected obstruction or another structural abnormality requires direct surgical assessment.
CMS doesn’t publish an office rate for 54865 in Washington.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
On this page 9 sections
What 54865 covers
A urologist surgically examines the epididymis, the coiled structure alongside the testis, to assess a suspected abnormality that requires direct operative evaluation. One clinical setting is male infertility evaluation when an epididymal blockage is suspected. The service is performed in an operative setting; it is distinct from taking tissue solely for biopsy or removing a defined lesion or the epididymis itself.
Report the exploration when the operative work is directed at assessing epididymal anatomy, and document the indication, side, surgical approach, and findings. CMS assigns a 90-day major-surgery global period, including the day-before preoperative visit and related postoperative care. When multiple procedures are performed in the same session, the highest-valued procedure is paid in full and other procedures are subject to the standard 50% reduction. Modifier 50 is inappropriate for this code. Assistant-at-surgery payment requires documented medical necessity; co-surgeons and team surgery are not permitted.
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
Where 54865 pays more and less in Washington
| Payment locality | Office | Facility |
|---|---|---|
| Rest Of Washington | Unavailable | $339.28 |
| Seattle (King Cnty) | Unavailable | $369.14 |
How the 54865 rate is calculated
Each of 54865’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 54865
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 5.63Practice expense 3.71Malpractice 0.72
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 54865
54865 has a 90-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 54865
Epididymal exploration
| Rule | CMS value | What it means |
|---|---|---|
| Global period | 090 | Major surgery: the day before, the day of, and 90 days after are included. |
| Multiple procedures | 2 | Standard reduction: highest-valued procedure at 100%, others at 50%. |
| Bilateral (modifier 50) | 0 | The 150% bilateral adjustment doesn’t apply. |
| Assistant at surgery (80/81/82/AS) | 0 | Not paid without supporting documentation. |
| Co-surgeons (62) | 0 | Not permitted. |
| Team surgery (66) | 0 | Not permitted. |
| Professional/technical | 0 | Physician service: no professional/technical split. |
| Split (54/55/56) | 0.10/0.80/0.10 | Share of the payment for pre-op, the procedure itself, and post-op care. |
Global surgery period · 54865
Epididymal exploration
90-day global period ends
Dec 30, 2026
Covers Sep 30, 2026 through Dec 30, 2026 (92 days, including the day before surgery).
Visit on Oct 31, 2026
Day 30 of the 90-day post-op period: related follow-up care is included in the surgical payment.
Pre-op dayGlobal period
What modifiers do to the payment
Modifier 51 · payment effect
With and without the modifier
54865 without 51 · national facility
$336.01
Epididymal exploration
54865-51 · Second procedure: 50%
$168.01
When this isn’t the highest-valued procedure in the session, Medicare pays 50% of its fee schedule amount (the highest is paid at 100%).
54865 compared with similar codes
Compare codes
54865 vs 54800 vs 54830 vs 54840 vs 54860: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 54800Epididymal biopsy
- 54865 describes operative assessment of epididymal anatomy; 54800 is selected when the purpose is obtaining epididymal tissue for biopsy.
- 54830Epididymal lesion
- Choose 54865 for exploration without removal of a defined lesion. Choose 54830 when the operative service is excision of an epididymal lesion.
- 54840Spermatocele removal
- 54865 is exploration; 54840 is used when a spermatocele is surgically removed.
- 54860Epididymectomy
- Exploration assesses the epididymis; 54860 reports its removal. Do not substitute removal when the documented service is exploration.
54865 billing questions
When should 54865 be chosen instead of an epididymal biopsy?
Use 54865 when the operative service is exploration to assess epididymal anatomy, such as suspected obstruction. Use 54800 when the service is biopsy for tissue sampling.
Can a biopsy or lesion removal be separately reported during the exploration?
The operative report should identify any distinct sampling or treatment performed in addition to exploration. Apply the same-session multiple-procedure payment reduction when multiple procedures are reported.
Should modifier 50 be used when both epididymides are explored?
No. CMS identifies bilateral adjustment as inappropriate for this code, so modifier 50 should not be used.
What documentation supports reporting epididymal exploration?
Document the clinical reason for direct exploration, the side and structures assessed, and the operative findings. The note should make clear that the service was exploration rather than biopsy or removal.
Can an assistant surgeon be reported?
Assistant-at-surgery payment is allowed only when medical necessity is documented. Co-surgeon and team-surgery payment are not permitted for this code.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
Show the CMS file lines behind this rate
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