Wiki Diagnostic Lap or Discontinued Lap Chole

[DEEDEE]

A patient was scheduled for a lap chole due to symptomatic cholelithiasis but the surgeon was not able to perform the cholecystectomy due to significant adhesions of the omentum to the gallbladder as well as the transverse colon.
One interpretation of the operative note results in coding this as a diagnostic lap, while another interpretation results in coding a lap chole with the discontinued outpatient procedure after anesthesia modifier.

 

[jdibble]

A patient was scheduled for a lap chole due to symptomatic cholelithiasis but the surgeon was not able to perform the cholecystectomy due to significant adhesions of the omentum to the gallbladder as well as the transverse colon.
One interpretation of the operative note results in coding this as a diagnostic lap, while another interpretation results in coding a lap chole with the discontinued outpatient procedure after anesthesia modifier.

From what the note says it looks like he did more than just a diagnostic lap as he tried to take down the adhesions, etc. It also stated that the procedure was aborted. I would code it as a discontinued lap chole.

 

[DEEDEE]

I agree. So, in your opinion, how would you code this case?

 

[jdibble]

I agree. So, in your opinion, how would you code this case?

I would code it 47562-53.

 

[DEEDEE]

I would code it 47562-53.

Thanks, Jodi. That's how I coded it as well. My provider was disagreeing and felt it should be coded as a diagnostic lap. I thought it would be helpful to have a non-biased opinion. I appreciate your time.