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Scenario Week of March 02, 2011:
View Current Scenario

Preoperative Diagnosis: Impalpable left testicle
Operation:
  1. Left inguinal exploration
  2. Left inguinal orchiectomy

History: Patient is a 13-month-old boy who was referred due to impalpable left testicle. The right testicle is normally descended and located within the right hemiscrotum. A previous inguinal and testicular ultrasound indicated the left testicle is normal which is surprising given it is not palpable. Additionally, this report indicates the right testicle is located within the inguinal canal which is also surprising since it is positioned within the scrotum and was not previously thought to be in the inguinal canal. Due to this confusion, I reviewed the images and can see the right and left side appear healthy and normal. Based on this, it was determined that an intraoperative ultrasound would be necessary. Due to the impalpable testicle, it is possible the location may be intra-abdominal and that a laparoscopy may be helpful in planning the incision. However, after the ultrasound report came back, it showed unequivocally there were testicles on both sides in the inguinal canals and in the scrotum. The laparoscopy was cancelled and a decision was made to proceed with an intraoperative ultrasound and a left inguinal exploration. The mother was notified about the possible risks and complications as well as the possible need to proceed with orchiectomy and consent was given.

Procedure: The patient was properly anesthetized after being identified and placed in the supine position. Ultrasound was performed on his left inguinal, scrotal, and abdomen areas. The right testicle was descended but the left testicle was nowhere to be found–unable to locate within the left scrotum, left inguinal canal, or intra-abdominal area including lateral to the bladder. This left two possibilities: either the testicle is atrophic and could be either intra-abdominal or canalicular, or there is a testicle inside the abdomen somewhere that cannot be detected by ultrasound. I elected to proceed with left inguinal exploration. The patient was prepped and draped in the usual fashion. An incision was made between the anterior superior iliac and the pubic tubercle on the left side. The incision was carried down through the skin, subcutaneous fat, and scarpas fascia. Superficial venous channels were carefully ligated with 4-0 chromic suture. The external ring was identified. I was able to see clearly that there was a vessel and a vas coming out of the external ring, ending in an atrophic small testicle with a black central scar. The gubernaculums testis was identified and was going all the way down to the scrotal skin, which was transected. The testicle was delivered into the field and the tunica vaginalis of that testicle was incised. The testicle was visualized. It was approximately 1/10 the size of the contralateral testicle. There appeared to be torsion in the cord above it whereby there was approximately 350 degree plus of rotation which was in a counterclockwise fashion that may have been responsible for the atrophy. In retrospect, the mother indicates that when the child was born his testicles were descended on both sides based on physical examination, so it appears the torsion occurred between the age of 2 months and now. In any event, the testicle was felt to be nonviable and removal was elected to include a portion of the superior cord. Careful palpitation of the wound and inguinal region failed to reveal any additional structure. The specimen in formalin was sent to pathology and I ligated the cord serially with 4-0 vicryl and 3-0 chromic. Hemostasis was good. The subcutaneous layer and scarpas fascia were closed with running 3-0 chromic suture and the skin was closed with 4-0 vicyrl subcuticular running suture. There were no complications. Bleeding was minimal. The patient was sent to recovery in satisfactory condition with a Tegaderm dressing.

Assign the appropriate ICD-9-CM and CPT codes for the procedure above.


ICD-9-CM
608.3Atrophy of testes

CPT
54520Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach
76998Ultrasound guidance, intraoperative

Rationale

It would not be appropriate to report ICD-9-CM code 752.51 even though the left testicle is undescended because the documentation clearly indicates this was not present at birth, and, therefore, is not a congenital condition.

It would not be appropriate to report CPT 54550 in conjunction with the orchiectomy based on the following instruction noted in CPT Assistant:

"Exploration: Testis

A new subheading titled Exploration was added to both the Testis and the Epididymis subsections for CPT 2007 to include codes that describe exploration without excision because the exploration codes are not excisional codes. Therefore, codes 54550, Exploration for undescended testis (inguinal or scrotal area), and 54560, Exploration for undescended testis with abdominal exploration, were moved under the new subheading Exploration."

 

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