S616 – Abscess or haematocele - and exploration - unilateral
OHIP Urology Code — MALE GENITAL SURGICAL PROCEDURES · Schedule of Benefits
This procedure involves the surgical incision and exploration of an abscess or haematocele affecting one side of the scrotum. The '#' prefix indicates that for services performed in a hospital or an Integrated Community Health Services Centre (ICHSC), the premises, equipment, supplies, and personnel are funded through the facility and are not separately billable by the physician. See for details.
When to Use
- Use S616 for the surgical drainage and exploration of a scrotal abscess where the procedure is confined to one side.
- Use S616 for the evacuation of a scrotal haematocele following trauma, provided the exploration is limited to a unilateral approach.
- Use S616 when the clinical intent is the surgical management of a collection (abscess or blood) rather than a simple suture of a laceration, which would fall under the Integumentary section.
Common Pitfalls
- Billing S616 bilaterally is incorrect; if both sides are explored, you must use the appropriate bilateral code or modifier if applicable, as S616 is explicitly defined as unilateral.
- Confusing S616 with minor skin procedures; if the procedure is merely a superficial incision of a skin abscess, ensure it does not overlap with lower-level integumentary codes that might be more appropriate for simple drainage.
- Failing to document the 'exploration' component; simply draining a collection without documenting the exploration of the scrotal contents may lead to audit scrutiny regarding the complexity of the procedure performed.
Billing Tips
- Always ensure the diagnosis code on the claim matches the surgical findings (e.g., abscess vs. haematocele) to support the necessity of the exploration.
- If the procedure is performed in a hospital setting, remember that the '#' prefix confirms that facility fees are covered by the hospital, so do not attempt to bill for tray or equipment fees separately.
Effective: April 1, 2026
U. Male Genital Surgical Procedures
MALE GENITAL SURGICAL PROCEDURES
Surgical
Male Genital Surgical Procedures
Male
For suture of lacerations, refer to the general listings under Integumentary System Surgical Procedures - Skin and Subcutaneous Tissue - Suture of Lacerations. Where suture of lacerations is the sole procedure and is done under general anaesthesia, refer to code E530.
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