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A needle biopsy of the epididymis is a minimally invasive procedure that involves the extraction of tissue samples from the epididymis, which is a coiled tube located at the back of the testis responsible for storing and maturing sperm. This procedure is typically performed under local anesthetic, allowing the patient to remain awake and comfortable while minimizing pain. The patient is positioned supine, meaning they lie on their back, which facilitates access to the scrotum. Prior to the biopsy, the scrotum is carefully prepared and draped to maintain a sterile environment, reducing the risk of infection.
During the procedure, the surgeon palpates the testis within the scrotal sac to locate the epididymis, which is then stabilized using the surgeon's index finger and thumb. This stabilization is crucial for accurate needle placement. The scrotal skin is stretched tightly to create a clear pathway for the needle, and a small incision is made with a scalpel to allow access to the epididymal tissue. A spring-loaded needle is then utilized to penetrate the incision and collect tissue samples from the epididymis. These samples are critical for further analysis, as they are sent to a pathologist who examines them for the presence of cancerous or abnormal cells. This examination is conducted as a separate reportable procedure, emphasizing the importance of the biopsy in diagnosing potential health issues related to male reproductive health.
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The needle biopsy of the epididymis is indicated for various clinical scenarios where there is a need to investigate abnormalities in the epididymal tissue. The following conditions may warrant this procedure:
The procedure for a needle biopsy of the epididymis involves several critical steps to ensure accurate tissue sampling. First, the patient is positioned supine on the examination table, allowing optimal access to the scrotum. The area is then prepared and draped in a sterile manner to minimize the risk of infection. Local anesthetic is administered to the scrotal area to ensure the patient experiences minimal discomfort during the procedure.
After the needle biopsy of the epididymis, the patient may be monitored for a short period to ensure there are no immediate complications, such as excessive bleeding or infection. It is common for patients to experience some discomfort or swelling in the scrotal area following the procedure, which can typically be managed with over-the-counter pain relief medications. Patients are advised to avoid strenuous activities and heavy lifting for a few days to facilitate healing. Follow-up appointments may be scheduled to discuss the results of the tissue analysis and any further management that may be necessary based on the findings.
| Short Descr | BIOPSY OF EPIDIDYMIS | Medium Descr | BIOPSY EPIDIDYMIS NEEDLE | Long Descr | Biopsy of epididymis, needle | Status Code | Active Code | Global Days | 000 - Endoscopic or 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) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 116 - Diagnostic procedures, male genital |
| 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. | RT | Right side (used to identify procedures performed on the right side of the body) |
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