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Gastroenterology Coding Alert

Reader Question:

Provide Adequate Documentation to Ensure Reimbursement for Unlisted Procedures

Published on Wed Sep 12, 2012

Question: Our gastroenterologist recently performed a laparoscopic procedure on a patient with lymphoid hyperplasia of the lateral aspect of the cecum. He used electrocautery to excise hypertrophic lymph nodes of the folds. The excised tissue was sent to pathology for study. Can you please let me know how I should report the procedure as I am not seeing any relevant code for this procedure under laparoscopic procedures for the lymphatic system?New Jersey SubscriberAnswer: As you have rightly indicated, there is no specific CPT® code to describe a laparoscopic excision of the lymphatic tissue using electrocautery. Since there is no specific code for the procedure, you will have to settle down with reporting 38589 (Unlisted laparoscopy procedure, lymphatic system).Since you're reporting an unlisted code, you will have to provide documentation explaining in detail about the procedure that your gastroenterologist performed also providing information on the time involved in carrying out the [...]
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