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Exploratory laparotomy with small bowel resection

E. maria Posted Tue 02nd of June, 2015 01:49:27 AM

A patient underwent a lap converted to open cholecystectomy, due to dense adhesions an enterotomy was made by the trochar placement and this was repaired. The following day the patient was taken back to surgery for exploratory laparotomy with evacuation of hematoma due to postoperative bleeding. Unfortunately, during the course the exploration the small bowel was evicerated and the previous small small bowel repair was disrupted and for this reason a limited small bowel resection was undertaken. Can I bill for the CPT 49002 and 44120?

SuperCoder Answered Tue 02nd of June, 2015 03:03:35 AM

Well, in CPT 49002 the provider reopens a previous abdominal incision to check for complications, such as internal bleeding or infection, which is not of your case, so CPT 44120 is appropriate with modifier 78.

E. maria Posted Wed 03rd of June, 2015 00:22:14 AM

But he did take the patient back to surgery for exploration due to bleeding and evacuation of the hematoma. During the exploration the small bowel was evicerated and therefore the small bowel resection. Is it appropriate to also charge for the small bowel resection if the eviceration happened during the exploration?

SuperCoder Answered Wed 03rd of June, 2015 01:38:45 AM

Well, in that case 49002 also can be coded. Use modifier 59 with CPT 49002 as there is CCI edits bundling between the CPTs.

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