Wiki Orchiectomy

[KaylaRieken]

If a physician documents he did an orchiectomy for a testicular tumor but doesn't specify if it's a radical do I code it a simple?

 

[daniel]

I’d query the physician, but if you can’t. I’d default to simple.

 

[csperoni]

I second the above. I don't deal with male patients, but I get this issue all the time with vulvectomies. If the op note doesn't specify, but you can interpret in the body of the op note (stating they removed tumor plus surrounding tissue to depth of Xmm or something like that), I won't query the physician. But if it's not 99.99% clear, then I query. If no response, I default to simple.

 

[liqgold2@aol.com]

I agree. The best thing to do is ask the urologist about his approach for the orchiectomy
Michael A. Ferragamo MD, FACS, urology coding and reimbursement consultant

 

[Coder 646]

I have a doctor that insists she did a radical orchiectomy. According to the CC book, definition is for tumor, but it's a mass and path stated hematoma, also no exploration or biopsy of lymph nodes. She Doesn't want the 54520 stating it wasn't simple. Should I put a -22 modifier on the 54520? Does the word "tumor" and the lymph node exploration/biopsy/excision need to be stated in the documentation before 54530 is supported?

 

[liqgold2@aol.com]

As answered previously, if the preoperative diagnosis is testicular tumor, then a radical orchiectomy, 54530, becomes the procedure of choice without biopsy or node resection.