Dawn C Posted Thu 26th of March, 2015 07:23:02 AM
How would this be coded?
A Phannensteil incision was made sharply and dissection was carried down to the fascia with electrocautery. The fascia was opened along the midline and dissection was carried through the abdominal raphe to separate the rectus muscles. The preperitoneal space was entered and dissected buntly, there was extensive clot within this space, the overflow blood was aspirated. Seven laparotomy pads were packed within the preperitoneal space and the fascia was closed with a running #1 PDS suture. The skin was closed with staples. A dry sterile dressing was applied.
SuperCoder Answered Fri 27th of March, 2015 08:02:59 AM
The procedure seems to be the exploratory laparotomy. I would only code CPT 49000. Had there been a vessel ligated, I would have also opted an additional code for it depending on the vessel.
Dawn C Posted Fri 27th of March, 2015 10:11:51 AM
Dawn C Posted Fri 27th of March, 2015 10:36:07 AM
My physician responded with this.
The problem with that is sometimes we do a formal ex lap at the same time to deal with intra abdominal injuries. And then the above procedure is done as well for the pelvic packing. How could we appropriately bill both procedures?
SuperCoder Answered Mon 30th of March, 2015 10:04:43 AM
I would still suggest to bill only ex lap CPT code for both of the procedures as pelvic packing is included in the procedure.
Dawn C Posted Mon 30th of March, 2015 10:06:56 AM
That was my thought too. Thanks again for your help
SuperCoder Answered Mon 30th of March, 2015 14:00:38 PM