tci General Surgery Coding Alert - 2002 Issue 5

Reader Question: Groin Exploration without Hernia

Question: Our surgeon suspected the patient was suffering from an inguinal hernia, but did not find one when he explored the groin. Should we report this as 49000? Idaho Subscriber Answer: Code 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]) should not be reported. The surgeon performed the exploration, thinking he would repair an inguinal hernia. Although hernia repair was not performed, the procedure was completed in that the exploration was performed and the patient closed. Therefore, the appropriate inguinal hernia repair code (most likely 49505) should be billed, with modifier -52 (Reduced services) appended. If...

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