Question

What are the ICD-10-PCS code for this?  

PROCEDURE PERFORMED:
1. Right scrotal exploration, and right spermatocelectomy.
2. Left scrotal exploration and left orchiectomy.
INDICATIONS: This 55-year-old gentleman was admitted to this Hospital approximately 4 months ago with bilateral testicular pain and swelling and enlargement. Ultrasound revealed a cystic mass of the right scxxtum consistent with right hydrocele. On the left side, the patient had severe left epididymitis/orchitis that turned to an abscess with spontaneous drainage. Subsequent ultrasounds revealed essentially no vascular flow to the left testis and the testis gradually became smaller, but it was painful to the patient. The patient requested surgery because of pain in the left side and because of enlargement of the right side, which he states interfered with his sexual activity. The patient was advised that following that spermatocelectomy on the right side, the patient could have recurrence of the spermatocele/bleeding/infection and pain.
DESCRIPTION OF PROCEDURE: After satisfactory general anesthesia, the patient was prepped and draped in a supine position. An incision was made in the midline of the scxxtum vertically. The right testis was exposed and delivered from the incision. This was done within the sac of the spermatocele. Spermatocele was identified, being adherent to the right epididymis. There was significant adherence and numerous small blood vessels present and adherence of the spermatocele sac to both the testis and the epididymis. Dissection was done sharply. The sac was excised, sent to histology. Care was taken to preserve the blood supply to the right testis. The small bleeding points were cauterized or suture ligated. Hemostasis was also directed towards the scrotal wall. Again, these were controlled by fulguration or suture ligature. The testis was placed back into its anatomic position on the right scrotal sac. A 5/8 Penrose nurse drain was left indwelling and brought out a separate stab incision.
Attention was then directed to the left scrotal cavity where it was incised, exposing the left testicle with much difficulty because of the abscess formation the patient had. This required total sharp dissection, which we also incurred some numerous bleeding points. These were controlled by cauterization. Finally, the spermatic cord was isolated. It was clamped and spermatic cord cut and the testicle was then removed. The bleeding points were controlled with ties of 2-0 Vicryl. Both scrotal cavities were irrigated thoroughly. As on the right side, a Penrose drain was left indwelling brought out separate stab incision, and then the wound was closed with interrupted sutures of 3-0 chromic catgut. Sterile dressings were applied as well as a scrotal support and the patient taken to recovery room in good condition.

Answer 1