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Radical orchiectomy, also known as orchidectomy, is a surgical procedure performed to remove one or both testicles, typically due to the presence of a known or suspected tumor. This procedure is executed through an inguinal incision, which is a cut made in the groin area. The incision is generally 4-6 cm in length and is positioned superior to the pubic bone, running parallel to the inguinal ligament on the side where the tumor is located. The surgery involves several critical steps, including the dissection of the spermatic cord and the removal of the testis, along with any associated structures. In the case of CPT® Code 54535, the procedure is further extended to include an abdominal exploration, which allows the surgeon to examine the abdominal cavity for any signs of tumor spread. This exploration is crucial for determining the extent of the disease and planning any additional treatments, such as lymphadenectomy, if necessary. The procedure is performed under sterile conditions, and meticulous attention is given to achieve hemostasis and ensure proper closure of the surgical site to promote healing and reduce the risk of complications.
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The radical orchiectomy procedure is indicated for the following conditions:
The procedure for radical orchiectomy with abdominal exploration involves several detailed steps:
Post-procedure care following a radical orchiectomy with abdominal exploration includes monitoring for any signs of complications such as bleeding or infection. Patients may require pain management and should be advised on activity restrictions during the recovery period. Follow-up appointments are essential to assess healing and to discuss any further treatment options, especially if lymphadenectomy was performed. The surgical site should be kept clean and dry, and any sutures or staples will be removed during follow-up visits as per the surgeon's protocol.
| Short Descr | EXTENSIVE TESTIS SURGERY | Medium Descr | ORCHIECTOMY RADICAL TUMOR W/ABDOMINAL EXPL | Long Descr | Orchiectomy, radical, for tumor; with abdominal exploration | Status Code | Active Code | Global Days | 090 - Major Surgery | 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) | 2 - Payment restriction for assistants at surgery does not apply 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 | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 118 - Other OR therapeutic procedures, male genital |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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). | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 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) |
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| Pre-1990 | Added | Code added. |
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