General Surgery Coding Alert

What to watch to avoid a $500 (or more) mistake If your surgeon must return a patient to the operating room for abdominal washout due to complication, don't select lavage code 49080 uncritically. In many cases, the procedure will qualify for a more extensive (and higher-valued) exploratory laparotomy. Know What 49080 Describes Surgeons will use the term "lavage" to describe washing out of abdominal wounds during an exploratory surgery, but you should be careful not to confuse this with lavage as defined by 49080 (Peritoneocentisis, abdominal paracentisis, or peritoneal lavage [diagnostic or therapeutic]; initial). During peritoneal lavage (49080) the surgeon introduces a saline solution into the peritoneal cavity through a catheter inserted through the abdominal wall (peritoneocentesis), then drains and collects the fluid. This fluid undergoes analysis for blood, chemical, or microscopic findings to diagnose, for instance, intra-abdominal trauma. "We use diagnostic peritoneal lavage in the trauma room and emergency department all the time when we are trying to evaluate an abdominal or thoracic injury," notes John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop & Associates. "We insert the peritoneal trocar and needle, frequently in the umbilicus, and flood in the saline looking for a backwash of blood, clots, tissue bits or infection fluid." To perform this procedure, the surgeon makes a small incision over the abdomen and inserts a catheter through which to introduce and withdraw the solution. Like peritoneocentesis or abdominal paracentisis, which involves draining fluid from the abdominal cavity, peritoneal lavage is a simple procedure requiring only local anesthetic. Key point: "Code 49080 does not involve opening the abdomen," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians (UWP) and Children's University Medical Group (CUMG) Compliance Program. "This is a great example of how fixating on a single term [lavage], or failing to read the entire operative report, can lead to mistakes," Bucknam continues. Washout Describes a Portion of Exploratory Surgery If the surgeon documents "lavage" in the operating room, you should not treat this washing or cleansing as the primary procedure. Rather, the lavage is only a component of a more extensive procedure, usually an exploratory laparotomy, and typically consists of dumping saline solution into the open peritoneal cavity. The surgeon removes the fluid by suction, also irrigating out blood or intraperitoneal contaminants. Exploratory laparotomy is a major procedure, with the patient under general anesthesia in an operating room. This may occur following trauma, for instance, or to treat post-operative complications such as infection. In such cases, "the correct coding is 49000 [Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure)] or 49002 [Reopening of recent laparotomy]," Bucknam explains. "The actual [...]