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Whitney Posted Tue 06th of March, 2018 20:11:21 PM
Challenging case while performing retroperitoneal lymph node dissection the physician encountered a 5cm paraaortic mass. States "This mass was very adherent to both the ureter as well as the aorta. Medially we did have to free it off of the aorta and did have to do this from both sides. We opened up the white line of Toldt on the left side going down the pelvis all the way up to the transverse colon and from there identified the left ureter and tacked it all the way up until we encountered the 5cm paraaortic mass. It was very adherent to the mass so we did have to then go about from the medial side trying to remove and free up the mass. We were able to peel the mass off both the ureter and the aorta using a Penfield Dissector. I know the code for the retro. lymph node dissection but having difficulty with the paraaortic mass being peeled off the ureter and aorta? What CPT codes would be used for this?
SuperCoder Answered Wed 07th of March, 2018 08:54:07 AM

Appropriate code for paraaortic mass excision would be 49203. 

Do also check your medical documentation for appropriate code of retroperitoneal lymph node dissection.; there might be bundling between both the codes.

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