How To Use CPT Code 54535

CPT 54535 describes the surgical procedure known as radical orchiectomy, which involves the removal of one or both testes to treat a tumor. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 54535?

CPT 54535 is a code used to describe the surgical procedure of radical orchiectomy. This procedure involves the complete removal of one or both testes to treat a tumor. It is typically performed by a qualified healthcare provider in a hospital or surgical setting.

2. Official Description

The official description of CPT code 54535 is: ‘Orchiectomy, radical, for tumor; with abdominal exploration.’ This code specifically refers to the surgical removal of one or both testes for the treatment of a tumor. It also includes an abdominal exploration to check for any spread of the disease into the abdomen.

3. Procedure

1. The healthcare provider begins by making an incision over the inguinal ligament, which is located in the groin area.
2. They continue the incision through the tissues and make a small incision into the external oblique fascia, which is a part of the external abdominal oblique muscle.
3. After freeing up the spermatic cord, the provider cross-clamps it and removes the testis and all its associated structures through the incision.
4. Great care is taken to avoid damaging important nerves and vessels in the area.
5. The provider then opens the cord, clamps, and removes the individual bundles of the cord to complete the removal of the testicle.
6. Bleeding is stopped using electrocautery, a process that uses heat from electrical current to cut and cauterize small vessels and tissues.
7. The external oblique fascia, subcutaneous fat, and skin are closed using sutures.
8. An artificial testis may be placed in the scrotum before suturing the incision closed.
9. After the orchiectomy, the provider performs an abdominal exploration by making an incision in the lower abdominal area.
10. They expose the rear wall of the abdomen and check the lymph nodes for any spread of malignancy.
11. A biopsy may be taken, and some lymph nodes may be removed for testing.
12. The abdominal wound is closed in layers using sutures.

4. Qualifying circumstances

CPT 54535 is performed on patients who have a tumor in one or both testes that requires surgical removal. The procedure is typically done to treat malignant tumors, which are cancerous and have the potential to spread if left untreated. The patient must meet the criteria for radical orchiectomy, and the healthcare provider must determine that this procedure is the appropriate course of treatment.

5. When to use CPT code 54535

CPT code 54535 should be used when a healthcare provider performs a radical orchiectomy for the treatment of a tumor. It is important to note that this code specifically includes an abdominal exploration to check for any spread of the disease into the abdomen. If the procedure does not involve an abdominal exploration, a different code should be used.

6. Documentation requirements

To support a claim for CPT 54535, the healthcare provider must document the following information:

• Patient’s diagnosis indicating the presence of a tumor in one or both testes
• Details of the surgical procedure, including the incision site and approach
• Documentation of the abdominal exploration, including any biopsies or lymph node removal
• Any complications or unexpected findings during the procedure
• Details of the closure of the incisions and any additional measures taken, such as the placement of an artificial testis or the use of a Penrose drain
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 54535, it is important to ensure that the procedure meets the criteria for radical orchiectomy for tumor removal. The healthcare provider should use the appropriate CPT code based on the specific details of the procedure. It is also important to follow any additional guidelines provided by the payer or insurance company.

8. Historical information

CPT code 54535 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A healthcare provider performs a radical orchiectomy on a patient with a malignant testicular tumor. The procedure includes an abdominal exploration to check for any spread of the disease into the abdomen.
2. During a radical orchiectomy, the healthcare provider discovers that the tumor has spread to the lymph nodes in the abdomen. They perform a lymph node dissection in addition to the removal of the testis.
3. A patient undergoes a radical orchiectomy for a benign tumor in one of their testes. The procedure is successful, and no further treatment is required.
4. A healthcare provider performs a radical orchiectomy on a patient with a testicular tumor. During the procedure, they discover that the tumor is larger than expected and has invaded nearby structures. They perform additional resection to ensure complete removal of the tumor.
5. A patient with a history of testicular cancer undergoes a radical orchiectomy as a preventive measure. The procedure is performed to remove the remaining testis and reduce the risk of recurrence.