Question

83. OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: History of left cryptorchid testicle.
POSTOPERATIVE DIAGNOSIS: Left ectopic testicle.
PROCEDURE PERFORMED: Left groin exploration with orchiopexy.
ANESTHESIA: General.
   Please see the preoperative note for indications of the procedure as well as full informed consent. This 14-year-old was recognized on a sports physical as having a nonpalpable testicle. Through his younger years, it had been palpable.
   The testicle on physical exam sat in the superficial inguinal canal next to the external ring. With him asleep, we went ahead and evaluated again and, again, the testicular cord was foreshortened, not allowing the testicle to get into the scrotum proper and sat slightly lateral as noted on the preoperative note.
   He underwent a general anesthetic as noted previously and was prepped and draped in the usual fashion. A transverse incision was made halfway between the anterosuperior iliac spine and pubic tubercle at the presumed location of the internal ring. The external oblique aponeurosis was opened along the course of its fibers to the external ring. The inguinal canal was opened. The external ilioinguinal nerve was identified and preserved. The testicle could be identified outside the inguinal canal lateral to it in its own small covering. This was opened and the cord, with the testicle, could be freed up. We removed some of the adhesions along the cord, which allowed very satisfactory length to allow it to fit well into the inferior aspect of the left hemiscrotum.
   A separate incision was made in the left hemiscrotum. Subdartos pouch was formed using sharp and blunt dissection. The testicle was brought through in a medial tract performed by using blunt dissection with a hemostat. The testicle was brought down into the scrotum and out of the incision with ease. On the inferior pole of the testicle, a small 3-0 chromic was placed in the inferior most portion of the septum. The scrotal wall was then closed over the testicle with interrupted 3-0 chromic. Irrigation of the wound was performed. No active bleeding could be identified. The external oblique aponeurosis was closed utilizing 3-0 silk. Bupivacaine 0.25% without epinephrine was placed approximately 3 ml in the internal ring and 3 ml in the subcut. The subcut was closed with interrupted 3-0 chromic and 4-0 undyed Vicryl for subcuticular incision closure with Steri-Strips. He tolerated the procedure well.
CPT Code(s): ______
ICD-10-CM Code(s): _______ , ______

Answer 1

The urologist has three options to do exploration inguinal, abdomen, and scrotal
while coding pays close attention to the operative report and important the additional details. this surgical approach included the followup procedure orchiopexy
Urologist complete exploratory exam and choose orchiopexy to correct undescended testicles
CPT code -54640
ICD -10-cm
Left cryptorchid testicle Q53.9
Left ectopic testicle Q53.01