Denise Posted Thu 24th of May, 2018 09:11:18 AM
Can this procedure be separately coded or would you list just 60545 for both. Exploratory laparotomy with, resection of infrarenal para-aortic paraganglioma and left adrenalectomy. The incision was extended for the paraganglioma.
Findings: 1) Left infrarenal paraganglioma 2) Left adrenal gland with approximately 4 cm mass. Thank you
SuperCoder Answered Fri 25th of May, 2018 05:25:18 AM
Yes, you just code 60545 with 22 modifier for both procedures as he is doing extra work for paraganglioma (extending incision for paraganglioma).
As per CPT 60545 “Once the physician gains access to the area, he explores the abdomen to identify the extent of disease. The provider may decide to biopsy suspicious sites and send them to pathology for immediate microscopic examination. He then isolates the adrenal glands and identifies any tumor or diseased gland or glands. He ties off the surrounding blood vessels of a diseased gland before removal to prevent excessive bleeding and then dissects the glands. He then releases and dissects the attached tissue of the gland from surrounding structures. If an adjacent retroperitoneal tumor is present, he carefully resects the mass along with a margin of uninvolved tissue and removes it together with the adrenal gland, sending the specimens to pathology for examination. The provider rinses the abdominal cavity with a sterile saline solution, closes the wounds, and sutures the incisions.”
Denise Posted Fri 25th of May, 2018 09:10:08 AM
SuperCoder Answered Mon 28th of May, 2018 00:53:19 AM