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A biopsy of the testis is a medical procedure that involves the removal of a small sample of testicular tissue for diagnostic purposes. This procedure is categorized as an incisional biopsy, which means that a surgical incision is made to access the testis directly, allowing for the collection of a tissue sample. The primary goal of this biopsy is to evaluate abnormalities within the testis, such as masses or the absence of living sperm, which may be indicative of underlying conditions affecting male fertility or testicular health. Prior to the procedure, the skin over the intended incision site is thoroughly cleansed to minimize the risk of infection, and a local anesthetic is administered to ensure patient comfort during the operation. Depending on the clinical indication, the surgeon may expose a mass within the testis to obtain a sample or may collect tissue to investigate cases of azoospermia, where no sperm is detected in the semen. The collected tissue is then preserved in Bouin's fluid and sent to a laboratory for histological evaluation, which is essential for diagnosing potential testicular disorders or confirming the presence of sperm in cases of infertility.
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The incisional biopsy of the testis is performed for specific clinical indications, which include:
The procedure for an incisional biopsy of the testis involves several critical steps to ensure accurate tissue sampling and patient safety.
After the incisional biopsy of the testis, the patient may be monitored for any immediate complications, such as bleeding or infection. Post-procedure care typically includes instructions for wound care, pain management, and activity restrictions to promote healing. Patients are advised to follow up with their healthcare provider to discuss the results of the histological evaluation and any further management that may be necessary based on the findings.
| Short Descr | BIOPSY OF TESTIS | Medium Descr | BIOPSY TESTIS INCISIONAL SEPARATE PROCEDURE | Long Descr | Biopsy of testis, incisional (separate procedure) | Status Code | Active Code | Global Days | 010 - Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 116 - Diagnostic procedures, male genital |
| 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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