Reviewed on April 21, 2015
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: How should I code the following:
The diagnosis was complex left adnexal mass.
Answer: First, determine the CPT® codes for each aspect of the procedure performed. In this case, 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]), 49203-49205 (Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; …), and 58740 (Lysis of adhesions [salpingolysis, ovariolysis]).
According to the Correct Coding Initiative (CCI), when a physician performs any open abdominal procedure is performed, he or she will routinely do an exploration of the surgical field to identify anatomic structures or any anomalies that may be present. Accordingly, you cannot bill an exploratory laparotomy (49000) separately with any abdominal procedure. Thus, you should eliminate 49000 from the list.
You’ll see that CPT® labels a diagnostic laparoscopy (49320) as a separate procedure. This statement indicates that the procedure, although it can be performed separately, is generally included in a more comprehensive procedure and the service may not be reported when a related, more comprehensive service is performed. This eliminates 49320 from the list.
This leaves the excision of the pelvis mass (49203-49205) and the lysis of adhesions (58740) as billable services. In order to select the correct code for the pelvic mass removal you will need to know the size of the excised mass. When multiple surgical procedures are reported, you should report the most expensive procedure first. You should apply modifier 51 (Multiple procedures) to the lesser of the two procedures — in this case, 58740.