Pelvic Mass Excision

AthensCoder

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Help!!!! I am stumped on this one. The patient underwent Abdominal exploration with enterolysis for a small bowel obstruction, apon exploration the surgeon found a pelvic mass. OP report reads as follows:

On inspection of the pelvis there was a round fatty mass, approximately 5x7 cm, well circumscribed, adjacent to and on top of the vaginal cuff. This was excised in its entirety.

Does anyone have any suggestions on the correct way to code this?:confused:
 
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49204?

I could be WAY off here, but ...

49204 The physician removes or destroys intraabdominal tumors, cysts, or endometriomas (displaced endometrial tissue) or primary or secondary mesenteric, peritoneal, or retroperitoneal tumors. The physician makes a large incision extending from just above the pubic hairline to the rib cage. The growths are removed using a laser, electric cautery, or a scalpel. The incision is closed with sutures. Report 49203 when the diameter of the largest tumor is 5 cm or smaller, 49204 when the diameter is 5.1 to 10 cm, and 49205 when the diameter is larger than 10 cm.

Your op report is SOooo brief! But I'm thinking this is what was being excised.
Do you have access to the pathology report?

I would NOT code the enterolysis or exploration.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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