Excision of scrotal mass Help.....

Surgeons123

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Hello fellow coders I was hoping if any one can help me finding a CPT code for the procedure I was thinking 54860 for the epididymectomy, but I'm not sure for the Excision of the mass. below is the operative report.


PREOPERATIVE DIAGNOSIS: Right scrotal mass
POSTOPERATIVE DIAGNOSIS: Right epididymal mass
PROCEDURE: Excision of right epididymal mass, distal epididymectomy.
ANESTHESIA: General LMA *
COMPLICATIONS: None. *
SPECIMEN: Right distal epididymis and right scrotal mass.
POST-OPERATIVE CONDITION: Stable. *
ESTIMATED BLOOD LOSS: Less than 5 ml. *
DRAINS: None. *
INDICATIONS: 51 year old male with prior history of vasectomy. The patient developed swelling and pain in a right scrotal mass. The symptoms did not resolve with antibiotics. He presents for excision of the mass. Risks and benefits discussed and informed consent obtained.
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OPERATIVE PROCEDURE: After obtaining informed consent, the patient was brought to the operating room and placed supine on the table. He underwent general anesthesia and was prepped and draped in sterile fashion. Timeout was performed and preoperative antibiotics administered. A mixture of ½ 1% plain Lidocaine and ½ ¼% plain marcaine was injected in the right hemiscrotum. A transverse scrotal incision was made with a 15 blade scalpel. Further dissection was performed with electrocautery. The testicle was delivered outside of the right hemiscrotum. A mas was identified at the posterior and inferior aspect of the testicle. This was carefully dissected free from the testicle. The tunica albuginea was opened to remove the mass. The distal aspect of the epididymis was excised by placing a Kelly Clamp across the epididymis. The distal epididymis and mass were excised together with the scalpel. A 3-0 Vicryl stick tie was placed for hemostasis. The mass and distal epididymis were passed off the table as specimen. The tunica albuginea was reapproximated with 4-0 Vicryl suture. Hemostasis was assured with electrocautery. The testicle and wound were irrigated. The testicle was placed back in the left hemiscrotum. The dartos muscle was closed with 3-0 Vicryl in a running fashion in two layers. The skin was closed with 2-0 Chromic in a running fashion. Antibiotic ointment and fluffs were placed as a dressing. The patient was awakened and transferred to the PACU in stable condition.
 
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