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Examination under anesthesia for impalpable difficult to assess left testes

  1. Default Examination under anesthesia for impalpable difficult to assess left testes
    Medical Coding Books
    Can't find a code to fit. There was on incision made just an exam under anesthesia

    in the supine position under general inhalational anesthesia, prior to prepping the patient we assessed his inguinal scrotal region bilaterally. in the supine position, he was relaxed and his airway manged by anesthesia and a bit of sedation was given. we were able to idnetify both testes within the inguinal canals and they were retrievable and would deliver to their dependent scrotal compartments. both were retactile and very small almost infantile. our final assessment was bilateral retractile testes. at this point, anesthesia was instructed to recover the patient and we took the pt to PACU.

    I'm thinking that this needs to be coded as an E/M instead of surgical code? Any thoughts?

    Thank you

  2. #2
    I agree with using an E/M code.

  3. #3
    Nashville AAPC Chapter
    I am curious why you would not use 54640, without reading the entire note to be absolutely positive.

  4. #4
    Milwaukee WI
    Default 55899
    You can not use 54640 because this was not performed; there was no repair done.

    You can not use 54550 - exploration for undescended testis - because there was no incision.

    I would use 55899 - Unlisted procedure, male genital system. I would charge half of what I would for 54550.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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