Testis

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Testis / Testicle: Click sections headings below (in blue) to expand or collapse the section content

Diagnostic Headings (i.e. specimen & procedure)

Diagnostic Headings		CPT Codes
	Left / Right testis, needle core biopsy:	88307 (tumor) or 88305 (non-neoplastic)
	Left / Right testis, biopsy:	88307 (tumor) or 88305 (non-neoplastic)
	Left / Right testis, cyst, excision:	? 88307 (tumor) or 88305 (non-neoplastic) ?
	Left / Right testis, orchiectomy:	88309 (tumor), 88307 (non-neoplastic), 88302 (castration)
	Left / Right testis and spermatic cord, orchiectomy:

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Diagnostic Menu -- Wording of Common Abnormalities

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Normal and Nearly Normal:

-- No diagnostic abnormality.

Trauma & Reactive Changes:

-- Extensive hemorrhagic necrosis consistent with testicular torsion.

-- Extensive interstitial fibrosis and organized tubular atrophy of the seminiferous tube.

-- Extensive hemorrhagic necrosis and tubal infarct consistent with trauma.

Developmental:

-- Completely atrophic testis with prominent fibrosis, old hemorrhage and dystrophic calcification.

-- Hypospermatogenesis and focal seminiferous tubule hypotrophy with mild peritubule fibrosis (see Note).

-- Benign testis with immature seminiferous tubes consistent with undescended testicle.

Neoplastic:

-- Pure seminoma (2.5 cm), confined in testis (see Tumor Synopsis and Note)

-- Mixed germ cell neoplasm with seminoma (__%), emryonal carcinom (__%) and yolk sac tumor (__%) (see Tumor Synopsis and Note)

Normal or Minimal Changes

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Clinical scenario: .

Left / Right testis, needle core biopsy:

-- No diagnostic abnormality (see Note).

Note: Specimen is submitted entirely for histologic examination. Multiple additional levels of the tissue blocks are examined.

Slides examined: H&E x 4

CPT code: 88305 x 1

Editor's comment:

This example include typical structural components and format that are used widely -- Diagnosis Heading, Main diagnosis, applicable Note or Comment (e.g. stain results), Slides examined and CPT codes. For diagnosis with complex attributes (e.g. of resected malignant tumor), a synoptic report (or "Checklis") must be included to comply with ACoS mandates. To prepare "Synoptic Report" with an on-line tool, go to Home page and click on Tumor Reporting. It usually takes less than 30% of the time required by routine dictation method.

Trauma, Degenerative / Reactive Changes

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Clinical scenario:

Right testis, orchiectomy:

-- Extensive hemorrhagic necrosis consistent with testicular torsion.

-- No abnormal spermatocytic maturation identified in residual focal viable seminiferous tubes.

-- No inflammation, granuloma or neoplasm.

Slides examined: H&E x 4

CPT code: 88307 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario:

Left / Right testis, orchiectomy:

-- Completely atrophic testis with prominent fibrosis, old hemorrhage and dystrophic calcification

-- No residual seminiferous tube or leydig cells present

-- No germ cell neoplasm identified

Slides examined: H&E x 4

CPT code: 88307 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario:

Left/Right testis, total orchiectomy:

- Extensive interstitial fibrosis and tubular atrophy of the seminiferous tube.

-- Focal Leydig cell hyperplasia.

-- No malignancy or intratubal germ cell neoplasm identified.

Slides examined: H&E x X

CPT code: 8830X x X

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario:

Right testis, total orchiectomy:

-- Extensive hemorrhagic necrosis and tubal infarct consistent with trauma.

-- No malignancy or intratubal germ cell neoplasm identified.

-- The spermatic cord resection margin is unremarkable.

Slides examined: H&E x 4

CPT code: 88307 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

Development Abnormality

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Clinical scenario: .

Left testis, orchiectomy:

-- Benign testis with immature seminiferous tubes consistent with undescended testicle

-- No intratubal germ cell neoplasm, granuloma or ischemic infarct identified.

Slides examined: H&E x 4

CPT code: 88307 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario:

Left testis, orchiectomy:

-- Completely atrophic testis with prominent fibrosis, old hemorrhage and dystrophic calcification

-- No residual seminiferous tube or leydig cells present

-- No germ cell neoplasm identified

Slides examined: H&E x 2

CPT code: 88305 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario:

Slides examined: H&E x 2

CPT code: 88305 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario:

Left testis, biopsy:

-- Hypospermatogenesis and focal seminiferous tubule hypotrophy with mild peritubule fibrosis (see Note)

-- No leydig cell hyperplasia or significant stromal fibrosis

-- No intratubal germ cell neoplasia or malignancy identified

Note: Sections reveal sixty-four cross sections of the seminiferous tubules for evaluation. Twelve of these tubes are hypotrophic with minimal or no mature sperms (spermatozoon) identified. There is mild peritubal basement sclerosis around these atrophic seminiferous tubes. Maturation of spermatocytes is seen in the remaining tubules. Spermatozoon count is sixty-two per seminiferous tube (excluding those without sperms).

Slides examined: H&E x 4

CPT code: 88307 x 1

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario: .

Right testis, total orchiectomy:

-- Diffuse severe spermatogenic arrest, most likely secondary.

-- Marked chronic inflammation, granulation tissue formation and foreign body giant cell reaction of the tunica vaginalis and tunica albuginea consistent with scrotal abscess.

-- No intratubular germ cell neoplasm or malignancy.

Slides examined: H&E x X

CPT code: 8830X x X

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

Malignant Neoplasm

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Clinical scenario: .

Organ, site, surgical procedure:

-- Dx Heading above font = 04Heading; Style = 04DxHeadings.

Note: 02958203.

Slides examined: H&E x X

CPT code: 8830X x X

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

Benign or Borderline Neoplasm

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Clinical scenario: .

Right testicle, orchiectomy:

-- Sertoli cell tumor of the testis, not otherwise specified, 1.7 cm, confined to testicular parenchyma (see comment)

-- No involvement of rete testes or tunica albuginea seen

-- Normal spermatic cord

-- No tumor present at surgical margins

-- Uninvolved testicular parenchyma with no specific abnormality

Note: The diagnosis is supported by results of immunohistochemical stains. The tumor cells show mild to focal moderate cytological atypia. Mitotic rate is up to 3 /10 hpfs. No tumor necrosis or angiolymphatic invasion by tumor is seen. No other tumor component is present. Although all sertoli cell tumors are potentially malignant, the overall features in this case support a favorable prognosis.

Reference: young RH et al: Sertoli cell tumors of the testis, not otherwise specified: a clinicopathologic analysis of 60 cases. Am J Surg Pathol. 1998 jun;22(6):709-21

Slides examined: H&E x X

CPT code: 8830X x X

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.

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Clinical scenario: .

Right testicle and spermatic cord, radical orchiectomy:

-- Leydig cell tumor (see summary of findings and comment).

-- Diffuse aspermatogenesis / sertoli cell-only of seminiferous tubes.

-- No germ cell neoplasm is identified.

-- The spermatic cord resection margin is free of tumor.

Note: Approximately 10% of Leydig cell tumors are malignant. Unfortunately, the malignant potential as well as hormonal activity cannot be determined by tumor histology. Only the presence of metastasis is considered as the most reliable criteria for malignancy.

Slides examined: H&E x X

CPT code: 8830X x X

Editor's comment:

This section critics on the pro & con of the the wording. There will be 12-pt space after text paragraph.