Question: Our surgeon suspected the patient was suffering from an inguinal hernia, but did not find one when he explored the groin. Should we report this as 49000?
Answer: Code 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]) should not be reported. The surgeon performed the exploration, thinking he would repair an inguinal hernia. Although hernia repair was not performed, the procedure was completed in that the exploration was performed and the patient closed. Therefore, the appropriate inguinal hernia repair code (most likely 49505) should be billed, with modifier -52 (Reduced services) appended.
If the patient is an adult, the ICD-9 code that describes the symptom that brought the patient to the surgeon (pain or mass) should be used as the primary diagnosis. In pediatric cases involving a congenital defect, the surgeon repairs one side and looks at the other side to make sure it does not have the same problem. In that case, V71.89 (Observation for other specified suspected conditions not found) may be used.
Note: Modifiers -LT (Left side) and/or -RT (Right side) should also be appended as appropriate.