toria11
Guru
Hi! How would you code this since the hydrocelectomy was performed from an inguinal approach? Is 55040 my only option here despite the exploration? Thanks!
PREOPERATIVE DIAGNOSIS:
Acute left scrotum, rule out torsion; rule out tumor.
POSTOPERATIVE DIAGNOSIS:
Left hydrocele. Normal left testicle.
PROCEDURE PERFORMED:
Left inguinal exploration of the scrotum, left hydrocelectomy.
ANESTHESIA:
General laryngeal mask.
INDICATIONS:
The patient presented with a painful swollen left testicle that acutely painful, but ultrasound suggested no blood flow to the left testicle and a markedly enlarged left testicle compared to the right. It is felt that an inguinal exploration in case this was a tumor was indicated an urgent exploration in case this was torsion.
FINDINGS:
There was a tense left hydrocele. There was no evidence of torsion of the cord. The left testicle was hyperemic if anything, the left testicle was of normal size. There were no testicular masses. Hydrocelectomy was performed.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room after general laryngeal mask anesthesia. He was prepped in sterile fashion in supine position. The left inguinal incision was made over the course of the cord, dissect down the external oblique fascia, which was incised with a knife. The ilioinguinal nerve was retracted and the cord was surrounded and visualized. No torsion of the cord was noted. Testicle and hydrocele were pulled out of the scrotum and then the hydrocele opened away from the incision and the testicle was noted to be normal in size. There were no masses in the testicle and the cord was not torsed. Hydrocelectomy was performed excising major portion of the hydrocele just to confirm blood flow of the testicle. Small incision was made in the tunica and bright red blood flowed out of the testicular contents. This incision was closed with an interrupted 3-0 Vicryl. Testicle was tacked back into the base of the scrotum and hemostasis was noted. External oblique fascia was closed with 2-0 Vicryl taking care not to involve the ilioinguinal nerve. Subcutaneous tissue closed with a running 3-0 Vicryl. Skin closed with staples. The cord and the incision were injected with 0.25% Marcaine. The patient was awakened from anesthesia after dressing the wound with an island dressing. He left the room in good condition.
PREOPERATIVE DIAGNOSIS:
Acute left scrotum, rule out torsion; rule out tumor.
POSTOPERATIVE DIAGNOSIS:
Left hydrocele. Normal left testicle.
PROCEDURE PERFORMED:
Left inguinal exploration of the scrotum, left hydrocelectomy.
ANESTHESIA:
General laryngeal mask.
INDICATIONS:
The patient presented with a painful swollen left testicle that acutely painful, but ultrasound suggested no blood flow to the left testicle and a markedly enlarged left testicle compared to the right. It is felt that an inguinal exploration in case this was a tumor was indicated an urgent exploration in case this was torsion.
FINDINGS:
There was a tense left hydrocele. There was no evidence of torsion of the cord. The left testicle was hyperemic if anything, the left testicle was of normal size. There were no testicular masses. Hydrocelectomy was performed.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room after general laryngeal mask anesthesia. He was prepped in sterile fashion in supine position. The left inguinal incision was made over the course of the cord, dissect down the external oblique fascia, which was incised with a knife. The ilioinguinal nerve was retracted and the cord was surrounded and visualized. No torsion of the cord was noted. Testicle and hydrocele were pulled out of the scrotum and then the hydrocele opened away from the incision and the testicle was noted to be normal in size. There were no masses in the testicle and the cord was not torsed. Hydrocelectomy was performed excising major portion of the hydrocele just to confirm blood flow of the testicle. Small incision was made in the tunica and bright red blood flowed out of the testicular contents. This incision was closed with an interrupted 3-0 Vicryl. Testicle was tacked back into the base of the scrotum and hemostasis was noted. External oblique fascia was closed with 2-0 Vicryl taking care not to involve the ilioinguinal nerve. Subcutaneous tissue closed with a running 3-0 Vicryl. Skin closed with staples. The cord and the incision were injected with 0.25% Marcaine. The patient was awakened from anesthesia after dressing the wound with an island dressing. He left the room in good condition.