CPT code(s) and indicate the index entries
Preoperative Diagnosis: Right hydrocelePostoperative Diagnosis: Right spermatocele
Operation: Right spermatocelectomy
Indications for Procedure: This 54-year-old male has a history of
right-sided scrotal enlargement. Scrotal ultrasound preoperatively was
consistent with right hydrocele.
Operation: The patient was brought to the operative suite, placed in
supine position and general anesthesia was administered. His scrotum
was shaved. He was then sterilely prepped and draped in the usual
manner. A transverse incision across the right hemiscrotum was then
made approximately 3.5 cm in length using electrocautery to further
dissect this area. The right-sided fluid sac was then exuded from the
right hemiscrotum. It seems to be a right spermatocele. Using
meticulous care and caution, the spermatocele was divided from the
testicle and the vas deferens was identified. There as a moderate
degree of difficulty as the spermatocele had separated the epididymis
from the patient’s right testicle. Using meticulous care, this was divided
free from his spermatocele. The spermatocele was handed off intact to
the scrubbed personnel. Hemostasis was achieved. The epididymis was
then re-attached to the testicle. The testicle was then replaced into the
right hemiscrotum. The wound was closed using a #2-0 locking running
chromic stitch and the superficial skin was closed in a horizontal
mattress fashion. Patient tolerated the procedure well and was sent to
recovery in satisfactory condition.
Pathology Report: spermatocele
Assign appropriate CPT code(s) and indicate the index entries.
Appending modifiers are optional, but would be good practice.
Code(s):__________________
Index entries: ___________________
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