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negative exploratory laparoscopy

  1. #1
    Default negative exploratory laparoscopy
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    It's me again My doctor did an exploratory lap looking at the right and left ovaries, right and left colon, uterus, rectum, gallbladder, upper abdomen- His pre-Op DX is ovarian cyst. What CPT code do I use? I came up with just 58578 for unspecified but is there something better? And can I still use ovarian cyst for a DX or do I need to use something else?

    Thank you!

    Brooke Bierman, CPC, CPB
    Coding & Billing Manager
    2014 President AAPC Des Moines Chapter

  2. #2
    I would use code 49320 for an ex-lap. If you look a few codes down in the CPT book, code 49322 shows the aspiration of a cyst and has ovaries in parenthasis. If the doc didn't find an ovarian cyst, I wouldn't code it, did the patient have any abd pain or other symptoms you can code?
    Chrissy, CPC

  3. #3
    Hi Chrissy! I had originally gone with 49320, 49321, 58679, and 58578- that's where I started but since he didn't do anything, I narrowed it down to 49320 and 58578. I picked the one that resembled the uterus and ovaries lol! Other than him describing the surgery, he gave me absolutely nothing should I send it back?

    Brooke Bierman, CPC, CPB
    Coding & Billing Manager
    2014 President AAPC Des Moines Chapter

  4. #4
    I would ask him if he did anything more than the ex lap because if he didn't take any specimens and there is no pathology, that's all you can bill for. I think it's worth asking especially if he has said that he will document better, by bringing him examples, it can really help him learn too. Just tell him that all he documented was an ex lap so that's all you can code but if he did a more extensive procedure, you need to get the path report and need more documentation and he can do an addendum to what he's already dictated.
    Chrissy, CPC

  5. #5
    Awesome! Thank you Chrissy! This helps a lot!!!

    Brooke Bierman, CPC, CPB
    Coding & Billing Manager
    2014 President AAPC Des Moines Chapter

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