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Exploration for undescended testis, also known as cryptorchism, is a surgical procedure performed when one or both testes have not descended into the scrotum prior to birth. This condition is typically addressed surgically if the testes have not descended by the age of one year. The procedure involves a thorough exploration of the inguinal or scrotal area to locate the undescended testis. The surgical approach begins with an incision made in the skin above the pubic bone, following the natural line of the inguinal ligament, and can be performed on either the right or left side. The incision is carefully deepened through the layers of subcutaneous tissue until reaching the external oblique muscle. A precise incision is then made in the muscle to access the inguinal canal, allowing for the identification and potential repositioning of the undescended testis into the scrotum. If the spermatic cord is present, it is meticulously dissected from surrounding tissues. In cases where the testis or spermatic cord structures are not found, further exploration may be necessary, including abdominal exploration through a lower abdominal incision. This comprehensive approach ensures that any remnants of the testis or spermatic cord can be addressed appropriately, and if viable structures are identified, they can be repositioned into the scrotum. The procedure is critical for addressing undescended testes, which can lead to complications such as infertility or malignancy if left untreated.
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Exploration for undescended testis is indicated in the following situations:
The procedure for exploration of the undescended testis involves several detailed steps:
Post-procedure care involves monitoring the patient for any complications and ensuring proper healing of the surgical site. Patients may experience some discomfort and swelling in the area, which can be managed with appropriate pain relief. Follow-up appointments are essential to assess the position of the testis and the overall recovery process. If a staged procedure is required, further evaluations and interventions will be scheduled accordingly. Proper documentation of the procedure and any findings is crucial for future reference and potential follow-up care.
| Short Descr | EXPLORATION FOR TESTIS | Medium Descr | EXPL UNDESCENDED TSTIS INGUN/SCROTAL AREA | Long Descr | Exploration for undescended testis (inguinal or scrotal area) | 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 | 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) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 118 - Other OR therapeutic procedures, male genital |
| 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). | 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. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | LT | Left side (used to identify procedures performed on the left side of the body) |
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| Pre-1990 | Added | Code added. |
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