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The procedure described by CPT® Code 54830 involves the excision of a local lesion from the epididymis, which is a coiled tube located at the back of the testis responsible for storing and maturing sperm. This surgical intervention is typically performed when there is a need to remove abnormal tissue that may be causing symptoms or has the potential to develop into a more serious condition, such as cancer. During the procedure, the patient is positioned supine, meaning they lie flat on their back, which allows for optimal access to the scrotal area. The scrotum is then meticulously prepared and draped to maintain a sterile environment, minimizing the risk of infection. The surgeon may choose between two surgical approaches: a vertical median raphe incision or a transverse hemiscrotal incision. Both techniques involve incising the skin and underlying tissues down to the tunica vaginalis, which is the protective sac surrounding the testis. Once access is achieved, the testis and epididymis are carefully brought out of the dartos fascia, either through blunt dissection or by fully incising the tunica vaginalis. This careful handling is crucial to avoid damage to surrounding structures. After the lesion is identified, it is excised from the epididymal tissue. To manage any bleeding that occurs during the excision, electrocautery is employed, which uses electrical current to coagulate blood vessels. Following the excision, tissue samples are collected for pathological examination to assess for the presence of cancerous or abnormal cells, which is a separate reportable procedure. If the excised lesion is large, the tunica vaginalis may be sutured in a radial fashion to ensure proper closure and support. Finally, the testis is returned to its anatomical position within the scrotum, and the layers of the tunica vaginalis or dartos are closed, followed by the closure of the skin, completing the procedure.
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The excision of a local lesion of the epididymis, as described by CPT® Code 54830, is indicated for various conditions that may affect the epididymis. These indications include:
The procedure for excising a local lesion of the epididymis involves several critical steps, which are detailed as follows:
After the excision of the local lesion of the epididymis, patients are typically monitored for any immediate postoperative complications. Expected recovery includes managing pain and discomfort, which may be addressed with prescribed analgesics. Patients are advised to avoid strenuous activities and heavy lifting for a specified period to promote healing. Follow-up appointments are essential to assess the surgical site and discuss the results of the pathological examination. Any signs of infection, such as increased redness, swelling, or discharge from the incision site, should be reported to the healthcare provider promptly. Overall, the recovery process may vary depending on the individual patient's health status and the extent of the procedure performed.
| Short Descr | REMOVE EPIDIDYMIS LESION | Medium Descr | EXCISION LOCAL LESION EPIDIDYMIS | Long Descr | Excision of local lesion of epididymis | 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) | 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 | 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). | 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. | 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.) | 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.) | 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) | 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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