General Surgery Coding Alert

You Be the Coder:

Don't Forget Surgical Approach Documentation

Published on Tue Aug 12, 2014

Question: A patient had a malignant neoplasm of abdomen with obstruction and recurrent incisional hernia. The surgeon performed a needle core biopsy of a retroperitoneal mass, as well as a resection and anastomosis of the small intestine that involved an ileostomy, as well as a repair of the incisional hernia. How should we code the case?

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Answer: The question is difficult to answer because you don’t describe the surgical approach, and the surgeon may have performed the procedure either laparoscopically or as an open procedure.

Assuming that this is an open procedure, you should report the biopsy as 49010 (Exploration, retroperitoneal area with or without biopsy[s] [separate procedure]). On the other hand, if this was a percutaneous needle biopsy, you should bill 49180 (Biopsy, abdominal or retroperitoneal mass, percutaneous needle).

Regarding the resection and anastomosis of the small intestine, an appropriate code might be 44120 (Enterectomy, resection of small intestine; single resection and anastomosis), depending on the specifics of the procedure. On the other hand, if the ileostomy was just a temporary bypass, then a more appropriate code might be 44310 (Ileostomy or jejunostomy, non-tube).

The ventral hernia repair is likely bundled whether the procedure is open or laparoscopic. The hernia repair may be separately billable if you have good documentation indicating that the surgeon would not have repaired a hernia in that location in the normal course of exiting the abdomen.

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