Results 1 to 2 of 2

abdominal wall exploration

  1. #1
    Northeast Kansas AAPC
    Question abdominal wall exploration
    New Call-to-action
    Patient was felt to have an epigastric hernia. OP reads as follows:

    Abdomen was prepped and draped in a standard surgical fashion. I then proceeded to infiltrate local anesthetic at the site that had been premarked. This was about 2 cm above the umbilicus. Vertical incision was made about 3 cm in length using a 15 blade. Dissection was then carried sharply down to the subcutaneous fat down to the level of the fascia and I proceeded to clear all the fat off the fascia along the midline. At this point, I was not able to identify any evidence of a fascial defect. I proceeded superiorly a little bit further as well as inferiorly down to the umbilicus again. I was not able to defect any fascial defect. Once this was confirmed, I then proceeded to control for hemostasis. The wound was then closed in a two-layered fashion using a running 3-0 Vicryl stitch to reapproximate the deep tissue layers and a running 4-0 Monocryl subcuticular stitch to reapproximate the skin edges.

    If I use 49570 with a 52 modifier would that be correct? Also what kind of diagnosis code would I use?


  2. Default
    HERNIA A HERNIA is a protrusion of an internal organ or part of an organ through a tear, hole or defect in the wall of a body cavity (ie the abdominal wall muscle)- meaning the rectal facsia andthe abdominal Rectus muscle all shd have been weaked and the abdominal contents atleast the peritoneum should have been herniating through the defect.
    The surgeon did not cut through more than the fatty tissues( a kind of removal of the fatty tissues to visualize the fascia) and did not find a defect.
    This was a sort of negative herniorraphy. He would have found a sort of protrusion which contemplated for surgery. This can happen with female obese patients -a kin dof ventral /epigastric hernia like symptoms.
    As you said, there is no code for abddominal wall exploration but for FB removal, debriments which do not fit for our case under discussion

    well, the diagnostic code ICD-9 Vcode would help to support: V71x (V71.8 the 'evaluation' part being the 'exploration') which can be first listed diagnosis code ; CPT code: as you said ventral / epigastric hernia Repair code with reduced services. Payers may not accept this.

    For discussion perspectives, can I suggest some more?!

    The Repair code - Intermediate Repair be assigned ( taking it for granted this being a 'suspected wound from within' ??
    Or Wound exploration, penetration- taking it as 'suspected penetration from within' ??!!. then you have a code for this too!! Just a sort of kidding suggestion please; some times may click!

    My sincere suggestion is for a CPT code as you contemplated with a modifer for reduced service, with Diag code V 71.8. which can be first listed with a detailed procedural report from the surgeon.
    If the payer pass it on , we are off the hook.
    if not, let us try for the Repair code.
    Thank you for reading

Similar Threads

  1. Abdominal Wall Excision
    By easumma in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 09-12-2012, 02:33 PM
  2. abdominal wall excisions
    By chickelala in forum General Surgery
    Replies: 1
    Last Post: 07-25-2012, 10:39 AM
  3. Exploration/Explantation of FB, abdominal wall
    By ksb0211 in forum General Surgery
    Replies: 2
    Last Post: 10-11-2011, 12:44 PM
  4. Reclose of abdominal wall
    By pdaniel in forum Gastroenterology
    Replies: 1
    Last Post: 12-09-2010, 01:26 PM
  5. us abdominal wall
    By srinivas r sajja in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 03-05-2009, 04:43 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.