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exploratory laparotomy and adhesiolysis

  1. #1
    Default exploratory laparotomy and adhesiolysis
    Medical Coding Books
    I can't tell on this report what exactly was done- It looks like the physician did an exploratory laparotomy. Does he have to say 'lysis of adhesions' in order to code that? The only thing I have is "the wall to wall adhesions were taken down sharply straightening out that segment of small bowel." He also collected some gelatinous material and sent to pathology. I'm thinking it should be coded with 49000 as an exploratory lap only. Any thoughts?


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

  2. #2
    Location
    Boise, Idaho
    Posts
    424
    Default
    It is really hard to tell from your note. It states right there that he did an enterolysis.

  3. #3
    Default
    It was two pages of exploration and a whole lot of typing So does this statement "the wall to wall adhesions were taken down sharply straightening out that segment of small bowel." mean he did 44005? Is that what 'take down' means? Here's the section that has that in it:

    ...The point of transition between the dilated bowel and decompressed bowel appeared to be an area where some tight adhesions within a 10 cm segment of small bowel produced an s-curve deformity of that segment although with palpation gas and fluid was able to pass through the area and seemed to indicate that it wasn't completely obstructed. The wall to wall adhesions were taken down sharply straightening out that segment of bowel. The area was carefully palpated....


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

  4. #4
    Location
    Boise, Idaho
    Posts
    424
    Default
    Yes. Sounds like it but you can't bill for the exploration and the lysis. Only one or the other.

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