General Surgery Coding Alert

Question: A patient with a prior gallstone surgery presents with a painful, fibrous abdominal mass. The surgeon performs an open procedure and finds a 7 cm gallstone embedded in the omentum extending into the peritoneal fat. The surgeon excises the gallstone granuloma with cautery. What diagnosis and procedure codes should I use?

Codify Subscriber

Answer: Based on your description, the best procedure code choice is 49255 (Omentectomy, epiploectomy, resection of omentum [separate procedure]). If the documentation had indicated that the gallstone extended into the peritoneal cavity, you might instead select a foreign-body removal code such as 49402 (Removal of peritoneal foreign body from peritoneal cavity).

The diagnosis code should take into account the history of cholecystectomy, which appears to explain the residual gallstone in the omentum, as though dropped during the previous surgery. In that case, report 998.4 (Foreign body accidentally left during a procedure not elsewhere classified). Without adequate documentation of the prior circumstances, you might choose to report 568.9 (Unspecified disorder of peritoneum) instead.