General Surgery Coding Alert

Question: Following a recent colectomy, the surgeon had to return to the OR for symptoms of intestinal leakage (purulent drainage, abdominal pain, and fever). The surgeon opened the defect, took swabs and submitted the specimen for culture, performed lavage, and finding no anastomotic leak, closed the site. How should we code this?

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Answer: The correct code is 49002 (Reopening of recent laparotomy). You should not additionally report the steps you describe, such as lavage (49084, Peritoneal lavage, including imaging guidance, when performed).

Because this is an unplanned return to surgery, you should append modifier 78 (Unplanned Return to the Operating/ Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period) to the procedure code. Modifier 78 is sometimes called the “post-op complication” modifier to indicate how it’s frequently used. Appending 78 to a code does not restart the global post-op period.

Avoid: Coders often misuse one of two other modifiers for a procedure following surgery during the post-op period. In this case, you should not use either 79 (Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period) or 58 (Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period). Those modifiers are not appropriate for this case because the return to the operating room (OR) was not planned, and was not unrelated.