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Epididymal exploration, with or without biopsy, is a surgical procedure aimed at investigating the epididymis, particularly in cases where infertility is suspected due to an obstructed epididymis accompanied by azoospermia, which is the absence of sperm in the semen. This procedure is typically indicated when there is a need to assess the condition of the epididymis, which is a coiled tube located at the back of the testis that plays a crucial role in the maturation and storage of sperm. The exploration is performed through a midline scrotal incision, allowing direct access to the epididymis. During the procedure, the testis is carefully delivered from the scrotal sac, and the tunica vaginalis, a protective layer surrounding the testis, is opened to facilitate examination of the epididymis. Utilizing an operating microscope, the surgeon can closely inspect the epididymis under magnification to identify any abnormalities. An obstructed epididymis typically presents with dilated tubules that may appear yellowish due to the accumulation of macrophages, which are immune cells that digest remnants of degenerated sperm that have been trapped due to the obstruction. If necessary, the surgeon may puncture or open the epididymal tunic to access the tubules for biopsy purposes. After the exploration and any biopsies are completed, the puncture sites or incisions in the tunic are meticulously closed, and the tunica vaginalis is sealed in a watertight manner to prevent inflammation and the formation of adhesions. Finally, the testicle is repositioned, and the scrotal incision is closed with sutures, ensuring proper healing and recovery.
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The procedure of epididymal exploration, with or without biopsy, is indicated in specific clinical scenarios where there is a suspicion of obstructed epididymis leading to infertility. The following conditions may warrant this surgical intervention:
The procedure of epididymal exploration involves several critical steps to ensure thorough examination and potential biopsy of the epididymis. The following procedural steps are undertaken:
Post-procedure care following epididymal exploration is essential for optimal recovery. Patients are typically monitored for any immediate complications, such as bleeding or infection. Pain management may be provided as needed, and patients are advised to avoid strenuous activities for a specified period to promote healing. Follow-up appointments may be scheduled to assess recovery and discuss biopsy results if applicable. It is crucial to monitor for any signs of inflammation or complications, ensuring that the tunica vaginalis remains sealed to prevent adhesions that could affect future fertility.
| Short Descr | EXPLORE EPIDIDYMIS | Medium Descr | EXPLORATION EPIDIDYMIS W/WO BIOPSY | Long Descr | Exploration of epididymis, with or without biopsy | 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) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | 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) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 116 - Diagnostic 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. | 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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| 2007-01-01 | Added | First appearance in code book in 2007. |
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