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Exploration for undescended testis, also known as cryptorchism, is a surgical procedure performed when one or both testes fail to descend 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 inguinal ligament, and can be performed on either the right or left side. The incision is carefully extended through the subcutaneous tissue to reach the aponeurosis of the external oblique muscle. A scalpel is then used to create an incision in the muscle, allowing access to the inguinal canal while preserving the ilioinguinal nerve. If the spermatic cord is identified, it is meticulously dissected free from the cremaster muscle, and the undescended testis is repositioned into the scrotum. In cases where spermatic cord structures or testicular remnants are found, they are removed, concluding the procedure. If no identifiable structures are present, the exploration continues into the abdominal cavity through a lower abdominal incision, where the peritoneum is accessed to search for the spermatic cord or testis. Depending on the findings, the procedure may involve further dissection and repositioning of the testis into the scrotum or may require a staged procedure if there are complications with length or blood supply. This procedure is critical for addressing undescended testes to prevent potential complications such as infertility or malignancy later in life.
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The procedure of exploration for undescended testis is indicated for the following conditions:
The procedure for exploration of an 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 to ensure that there are no complications such as infection or issues with blood supply. If a staged procedure is required, further evaluations and interventions will be scheduled accordingly. The surgical site should be kept clean and dry, and any signs of infection or unusual symptoms should be reported to the healthcare provider promptly.
| Short Descr | EXPLORATION FOR TESTIS | Medium Descr | EXPL UNDESCENDED TESTIS W/ABDOMINAL EXPL | Long Descr | Exploration for undescended testis 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) | 1 - Co-surgeons could be paid, though supporting documentation is required... | 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 | Non office-based surgical procedure added in CY 2008 or later; 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 |
| 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | QJ | Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b) | 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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