General Surgery Coding Alert

Question: Our surgeon treated an 11-month-old with bilateral undescended testes. The op report describes the surgeon using an endoscope through the umbilicus to view the testicle. The surgeon then executed an incision and dissection in the inguino-abdominal area before mobilizing the spermatic cord, bringing the testes down into the scrotum, and fixing it in place. What are the correct diagnosis and procedure codes for this case?

Super coder Subscriber

Answer: The appropriate diagnosis code is Q53.211 (Bilateral intraabdominal testes). The procedure code is 54650 (Orchiopexy, abdominal approach, for intra-abdominal testis (eg, Fowler-Stephens)).

Distinguish codes: If the surgeon had performed a laparoscopic procedure, the appropriate code would be 54692 (Laparoscopy, surgical; orchiopexy for intra-abdominal testis).

Similarly, you have other code options to describe the condition if the undescended testis was in a different location, as follows:

• Q53.111, Unilateral intraabdominal testis
• Q53.112, Unilateral inguinal testis
• Q53.13, Unilateral high scrotal testis
• Q53.211, Bilateral intraabdominal testes
• Q53.212, Bilateral inguinal testes
• Q53.23, Bilateral high scrotal testes.