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Right Inguinal exploration

Teresa Posted Wed 08th of January, 2020 12:54:49 PM
Advise please-Our physician plans to go in and do a inguinal exploration due to the patient having a palpable lesion of the right groin and the past history of prostatic cancer and also colon cancer. Incision done along the palpable mass. skin and subcutaneous tissue divided. Dissection done all the way down to this palpable region and found to be an area of plastic structure which was a portion of the saline. Not sure what CPT to use for this procedure. The physician was never made aware that the patient had a Penile implant pump. Any help would be greatly appreciated.
SuperCoder Answered Thu 09th of January, 2020 07:22:02 AM

Hi,

 

There is no specific CPT code which is only meant for inguinal exploration.

The surgeon performed the exploration, thinking he would remove the palpable mass. Although mass was not found, the procedure was completed in that the exploration was performed and the patient closed. Therefore, the appropriate mass removal codes (most likely 27047, 27043, 27048, or 27045) should be billed, with modifier -52 (Reduced services) appended. Exploration of the groin is an integral part of 27047/27043 and 27048/27045 and is therefore included in these procedures.

 

Review your surgeon documentation and the operative report. Then consider which of the following CPT® codes best describes the inguinal procedure:

27047(Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; less than 3 cm) or 27043 (...3 cm or greater) if the exploration was in the inguinal subcutaneous tissue, with excision of a subcutaneous mass, or

27048 (… subfascial [e.g., intramuscular]; less than 5 cm) or 27045 (... 5 cm or greater) if the exploration is deeper within the inguinal canal, with excision of a mass in the inguinal canal.

 

Thanks

Teresa Posted Thu 09th of January, 2020 08:33:40 AM
Thank you for your feedback. My thought was to also use the 27047 or the unlisted 53899 but others thought 38500 with 52 more appropriate.
SuperCoder Answered Fri 10th of January, 2020 04:36:56 AM

Hi,

 

CPT 53899 is reported for unlisted procedure for urinary system, the components of urinary system are kidneys, ureters, urinary bladder, and urethra. However, in above mentioned report surgeon has not worked on one of the components of urinary system, so CPT 53899 will be incorrect code.

On the other hand CPT 38500 is used for lymph node excision or biopsy.

 

Please also check below mentioned link:

https://www.supercoder.com/coding-newsletters/my-urology-coding-alert/you-be-the-coder-inguinal-exploration-and-mass-excision-article

 

Hope this helps!

 

Thanks

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