2025 CPT code 54560
Effective Date: N/A Surgery - Surgical Procedures on the Male Genital System Feed
Exploration for undescended testis with abdominal exploration.
Modifier 50 is used for bilateral procedures. Other modifiers may be applicable depending on the specific circumstances.
Medical necessity for this procedure is established by the diagnosis of an undescended testicle and the need to locate it for potential orchiopexy or to confirm its absence.Undescended testicles can lead to infertility and an increased risk of testicular cancer if left untreated.
The physician is responsible for preparing and anesthetizing the patient, making the incisions, performing the exploration, and potentially freeing, lowering, and securing the testicle if found. This includes managing any complications and providing post-operative care instructions.
In simple words: The doctor searches for an undescended testicle (a testicle that hasn't moved into its proper place in the scrotum). This may involve making a small cut in the groin or lower belly area to find the testicle. If the testicle is found, a separate procedure might be needed to bring it down to the scrotum. This can be done on both sides if necessary.
This procedure involves exploring for an undescended testicle (cryptorchidism), which may include exploration into the abdomen. It is performed to locate an undescended testicle or to confirm its absence.The provider makes an incision in the inguinal area, potentially extending it into the abdomen, to explore the groin and lower abdomen. If the testicle is found, a separate procedure may be performed to free it, lower it into the scrotal sac, and secure it with stitches. This exploration can be repeated for bilateral cases.
Example 1: A newborn male is diagnosed with an undescended right testicle. Code 54560 is used for the exploration performed to locate the testicle., A 6-month-old male infant has a non-palpable left testicle.An abdominal exploration (54560) is performed, and the testicle is found in the abdomen. A separate procedure (54650) is then performed to bring the testicle down and fixate it., A young boy has both testicles undescended. Code 54560 is reported with modifier 50 to indicate a bilateral exploration was performed.
Documentation should include physical exam findings, imaging results (if any), operative report detailing the exploration, location of the testicle (if found), any procedures performed to mobilize and fixate the testicle, and post-operative instructions.
- Specialties:Pediatric Urology, Urology, Pediatric Surgery, General Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center