Has anyone come across coding a circumcision with scrotal relaxation. is the relaxation included in the circumcision. if so, I was looking at CPT 54161/55250, help :/
PROCEDURE/SURGERY: Circumcision with scrotal relaxation, bilateral Vasectomy
SURGEON: Surgeon(s):
ANESTHESIOLOGIST:xxxxxx
ANESTHESIA TYPE: General
ESTIMATED BLOOD LOSS: 50 ml
COMPLICATIONS: None
FINDINGS: Large capacious scrotum, phimosis
SPECIMENS: None
INDICATIONS FOR SURGERY: 39 yom with undesired fertility and phimosis causing difficulty
SUMMARY OF PROCEDURE: The patient was brought into the OR and placed in the supine position. His genitalia and lower abdomen were then prepped and draped in a standard surgical fashion. A penile block was then performed with administration of approximately 8 ml of 0.5% Marcaine along the base of the penis and anterior to the pubic bone, deep into the pudendal nerve region using a 25G needle. The foreskin was then forcibly retracted back, using a curved clamp to facilitate releasing of attachments from the foreskin to the glans and coronal sulcus. A dense frenular attachment to the ventral glans was released by clamping the skin attachment and then sharply incising through. Cautery was performed to stop bleeding at the frenular incision.The borders of the circumcision was then marked leaving an inner cuff of preputial skin approximately 7-10 mm in width. The outer border was approximated by bringing the foreskin over the glans and marking at the level just proximal to the coronal ridge. A 15-blade scalpel was then used to incise along distal and proximal incision lines circumferentially to separate the excess foreskin. The foreskin was lifted off of the underlying Dartos tissue and released with electrocautery circumferentially. Bleeding points in the Dartos tissue were carefully observed and focally cauterized for hemostasis. The foreskin was then reconstructed by using a 3-0 Quill starting at the dorsal midline and suturing in a subcuticular fashion toward the frenulum. The operative site was observed, and no significant bleeding was noted. There was then seen to be a high scrotal insertion onto the ventral penis. A Y-V scrotal relaxation was then performed allow the scrotal skin to lie in a normal anatomic position.
The left vas deferens was identified and isolated. A blunt opening was made in the inferior edge of the scrotal opening. The vas was isolated and then brought out of the opening. 2-0 silk ties and small metal clips were then placed proximally and distally. A 2 cm segment between was cut and removed. The vas lumen was then cauterized. The vas was then allowed back into the scrotum. The right vas was then identified and a similar procedure was performed.
The scrotal aspect was closed using 3-0 Quill in a running subcuticular fashion. The incision was bonded with Dermabond. The patient tolerated the procedure well. The needles, sponge, and instruments counts were correct at the end of the case. The case was then completed. The procedure was then ended. The anaesthetic was reversed. The patient tolerated the procedure well with no immediate complications. He will fu in 6 weeks with a semen analysis.
PROCEDURE/SURGERY: Circumcision with scrotal relaxation, bilateral Vasectomy
SURGEON: Surgeon(s):
ANESTHESIOLOGIST:xxxxxx
ANESTHESIA TYPE: General
ESTIMATED BLOOD LOSS: 50 ml
COMPLICATIONS: None
FINDINGS: Large capacious scrotum, phimosis
SPECIMENS: None
INDICATIONS FOR SURGERY: 39 yom with undesired fertility and phimosis causing difficulty
SUMMARY OF PROCEDURE: The patient was brought into the OR and placed in the supine position. His genitalia and lower abdomen were then prepped and draped in a standard surgical fashion. A penile block was then performed with administration of approximately 8 ml of 0.5% Marcaine along the base of the penis and anterior to the pubic bone, deep into the pudendal nerve region using a 25G needle. The foreskin was then forcibly retracted back, using a curved clamp to facilitate releasing of attachments from the foreskin to the glans and coronal sulcus. A dense frenular attachment to the ventral glans was released by clamping the skin attachment and then sharply incising through. Cautery was performed to stop bleeding at the frenular incision.The borders of the circumcision was then marked leaving an inner cuff of preputial skin approximately 7-10 mm in width. The outer border was approximated by bringing the foreskin over the glans and marking at the level just proximal to the coronal ridge. A 15-blade scalpel was then used to incise along distal and proximal incision lines circumferentially to separate the excess foreskin. The foreskin was lifted off of the underlying Dartos tissue and released with electrocautery circumferentially. Bleeding points in the Dartos tissue were carefully observed and focally cauterized for hemostasis. The foreskin was then reconstructed by using a 3-0 Quill starting at the dorsal midline and suturing in a subcuticular fashion toward the frenulum. The operative site was observed, and no significant bleeding was noted. There was then seen to be a high scrotal insertion onto the ventral penis. A Y-V scrotal relaxation was then performed allow the scrotal skin to lie in a normal anatomic position.
The left vas deferens was identified and isolated. A blunt opening was made in the inferior edge of the scrotal opening. The vas was isolated and then brought out of the opening. 2-0 silk ties and small metal clips were then placed proximally and distally. A 2 cm segment between was cut and removed. The vas lumen was then cauterized. The vas was then allowed back into the scrotum. The right vas was then identified and a similar procedure was performed.
The scrotal aspect was closed using 3-0 Quill in a running subcuticular fashion. The incision was bonded with Dermabond. The patient tolerated the procedure well. The needles, sponge, and instruments counts were correct at the end of the case. The case was then completed. The procedure was then ended. The anaesthetic was reversed. The patient tolerated the procedure well with no immediate complications. He will fu in 6 weeks with a semen analysis.