tci General Surgery Coding Alert - 2015 Issue 3

You Be the Coder: Consider Source, Location for Removal Code Selection

Question: A patient with a prior gallstone surgery presents with a painful, fibrous abdominal mass. The surgeon performs an open procedure and finds a 7 cm gallstone embedded in the omentum extending into the peritoneal fat. The surgeon excises the gallstone granuloma with cautery. What diagnosis and procedure codes should I use? SuperCoder Subscriber Answer: Based on your description, the best procedure code choice is 49255 (Omentectomy, epiploectomy, resection of omentum [separate procedure]). If the documentation had indicated that the gallstone extended into the peritoneal cavity, you might instead select a foreign-body removal code such as 49402 (Removal of...

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