Debra Posted Mon 05th of February, 2018 16:31:11 PM
How would an abdominal exploratory surgery be coded for an open procedure (versus laparoscopic) for a possible hernia repair? Patient was morbidly obese so open exploration was performed and no hernia was found during exploration. Description of procedure is as follows:
The patient is brought to the operating room, put to sleep using general anesthesia with endotracheal intubation. Her abdomen was prepped and draped in the usual sterile fashion. The site of tenderness had been marked prior to coming to the operating room and indicated by the patient and confirmed to be the same spot that we had noted as tender on her original evaluation in the office. An incision was made over this area, which was lateral to the midline, left upper quadrant above the umbilicus. The incision was carried down to subcutaneous tissue. Dissection was carried down to the fascia. The fascia was _____. Flaps were raised medially and laterally to ensure that we were not offsite. There was no indication of any ventral hernia whatsoever. At this point, the wound was irrigated, hemostasis secured. Subcutaneous tissue closed with running 3-0Vicryl suture. Skin closed with 4-0 Vicryl subcuticular stitch. Steri-Strips, Telfa and Tegaderm dressings were applied. The patient was awakened and taken to the recovery room in stable condition.
SuperCoder Answered Tue 06th of February, 2018 04:10:01 AM
CPT 49999 (Unlisted procedure) is the most appropriate code to bill for the procedure. On the other hand, diagnosis "possible hernia repair" is not a correct diagnosis. As per guidelines, POSSIBLE conditions are not considered as definitive diagnosis. Make sure to append the definitive diagnosis or at least sign and symptoms in case definitive diagnosis is not present.
Also, when reporting a procedure with an unlisted code, submit a cover letter explaining the reason for choosing the unlisted code instead of a defined, active code. Also include the operative notes or other relevant documentation to strengthen the claim. Your payers will consider claims with unlisted procedure codes on a case by case basis, and they will determine payment based on the documentation you provide.