Hi! How would you code this? I was thinking 54640 for the Orchiopexy, but wasn't sure if the removal of appendix testis would be included in this? Thanks!!
POSTOPERATIVE DIAGNOSIS:
Intermittent testicular torsion.
PROCEDURE PERFORMED:
Prophylactic bilateral orchiectomy, scrotal approach
ANESTHESIA:
General.
FINDINGS:
1. Healthy viable testicles.
2. Removal of bilateral appendix testes.
3. Three-point fixation of each testicle in appropriate hemiscrotum.
INDICATIONS:
The patient is a 19-year-old Caucasian male who is evaluated for testicular pain in the office. In discussion with the patient, he frequently gets intermittent testicular pain that would wake him up from a deep sleep and cause severe anywhere from 6/10 to 8/10 testicular pain. He also notes some slight swelling and that his testicle would change its lie and applying horizontally. Each time he would go to a warm bath and relax and it would seem to relieve the pain and the testicle would go back to its normal position. In discussed with him, it sounds like he was having recurrent episodes of intermittent testicular torsion as these episodes were becoming more frequently and occurring on both sides. Treatment options were discussed with him and his family including observation versus prophylactic bilateral orchiopexy and the patient elected to proceed with the elective bilateral orchiopexy. After risks, benefits, and alternatives were explained to the patient and his family, the patient elected to proceed. Informed consent was obtained.
DESCRIPTION OF PROCEDURE:
The patient was properly identified, brought back to the operating room, was laid supine on the operating table. Proper time-out was performed. Under direction of Anesthesiology, the patient had been induced under anesthetic. Ancef 2 g IV was given 1 hour at the start of the procedure. The patient was then prepped and draped in normal sterile surgical fashion and he laid supine on the table. 0.25% Marcaine plain was then injected superficially on the scrotum on each side for local anesthetic purposes. At this time, a horizontal transverse incision was made on the left hemiscrotum and the testicle was delivered and remained in its proper orientation. At this point, the appendix testes was then removed. The testicle appeared to be viable and healthy. It was then placed back in the hemiscrotum and three-point fixation was done with 3-0 Prolene at the lateral, medial and inferior portion of the testicle. A second look was performed and the testicle was in proper orientation once it was properly fixed. The dartos layer was then closed with interlocking 3-0 Vicryl running suture. At this point, a symmetrical transverse incision was made on the right hemiscrotum. The testicle was then carefully delivered. Again, the testicle appeared to be viable and healthy. The appendix testis was then removed. The testicle was then placed back in proper orientation in the right hemiscrotum and a three-point fixation was done with 3-0 Prolene in the medial, lateral, and inferior margins. A second look was then performed to make sure the testicle was in proper orientation, which it was. Hemostasis was excellent on both sides. This was achieved through pinpoint electrocautery. The 3-0 Vicryl was used in a running fashion to close the dartos layer on the right side. The skin incision was then closed with 4-0 chromic on each side in a running fashion. This concluded the procedure. Sponge, instrument, and needle counts were correct at the end the case. Estimated blood loss was less than 25 mL. A scrotal support and dressing were applied at the end of the case. The patient was then extubated, sent to Recovery in
stable condition without immediate complications. He will be discharged home per PACU protocol with pain medications and antibiotics and he will follow up as scheduled for his postoperative visit. DS 20220223
POSTOPERATIVE DIAGNOSIS:
Intermittent testicular torsion.
PROCEDURE PERFORMED:
Prophylactic bilateral orchiectomy, scrotal approach
ANESTHESIA:
General.
FINDINGS:
1. Healthy viable testicles.
2. Removal of bilateral appendix testes.
3. Three-point fixation of each testicle in appropriate hemiscrotum.
INDICATIONS:
The patient is a 19-year-old Caucasian male who is evaluated for testicular pain in the office. In discussion with the patient, he frequently gets intermittent testicular pain that would wake him up from a deep sleep and cause severe anywhere from 6/10 to 8/10 testicular pain. He also notes some slight swelling and that his testicle would change its lie and applying horizontally. Each time he would go to a warm bath and relax and it would seem to relieve the pain and the testicle would go back to its normal position. In discussed with him, it sounds like he was having recurrent episodes of intermittent testicular torsion as these episodes were becoming more frequently and occurring on both sides. Treatment options were discussed with him and his family including observation versus prophylactic bilateral orchiopexy and the patient elected to proceed with the elective bilateral orchiopexy. After risks, benefits, and alternatives were explained to the patient and his family, the patient elected to proceed. Informed consent was obtained.
DESCRIPTION OF PROCEDURE:
The patient was properly identified, brought back to the operating room, was laid supine on the operating table. Proper time-out was performed. Under direction of Anesthesiology, the patient had been induced under anesthetic. Ancef 2 g IV was given 1 hour at the start of the procedure. The patient was then prepped and draped in normal sterile surgical fashion and he laid supine on the table. 0.25% Marcaine plain was then injected superficially on the scrotum on each side for local anesthetic purposes. At this time, a horizontal transverse incision was made on the left hemiscrotum and the testicle was delivered and remained in its proper orientation. At this point, the appendix testes was then removed. The testicle appeared to be viable and healthy. It was then placed back in the hemiscrotum and three-point fixation was done with 3-0 Prolene at the lateral, medial and inferior portion of the testicle. A second look was performed and the testicle was in proper orientation once it was properly fixed. The dartos layer was then closed with interlocking 3-0 Vicryl running suture. At this point, a symmetrical transverse incision was made on the right hemiscrotum. The testicle was then carefully delivered. Again, the testicle appeared to be viable and healthy. The appendix testis was then removed. The testicle was then placed back in proper orientation in the right hemiscrotum and a three-point fixation was done with 3-0 Prolene in the medial, lateral, and inferior margins. A second look was then performed to make sure the testicle was in proper orientation, which it was. Hemostasis was excellent on both sides. This was achieved through pinpoint electrocautery. The 3-0 Vicryl was used in a running fashion to close the dartos layer on the right side. The skin incision was then closed with 4-0 chromic on each side in a running fashion. This concluded the procedure. Sponge, instrument, and needle counts were correct at the end the case. Estimated blood loss was less than 25 mL. A scrotal support and dressing were applied at the end of the case. The patient was then extubated, sent to Recovery in
stable condition without immediate complications. He will be discharged home per PACU protocol with pain medications and antibiotics and he will follow up as scheduled for his postoperative visit. DS 20220223