tci General Surgery Coding Alert - 2017 Issue 5

Reader Question: Capture Multiple Abdominal Procedures

Question: The surgeon performed the following procedure for a patient with an abdominal mass and obstruction: percutaneous needle core biopsy of retroperitoneal mass, open temporary bypass ileostomy, and repair of recurrent incisional hernia. How should we code this? Mississippi Subscriber Answer: You should report the biopsy using 49180 (Biopsy, abdominal or retroperitoneal mass, percutaneous needle) because you specified a percutaneous approach. The best choice for the bypass ileostomy is most likely 44310 (Ileostomy or jejunostomy, non-tube), although more thorough documentation might indicate a different code. You shouldn’t typically separately report a hernia repair in the surgical field of...

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