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  1. #1
    Kansas City, MO
    Question Laparotomy
    Medical Coding Books
    Physician performed an exploratory laparotomy, pelvic washings, excision
    of vaginal cuff mass (focal fibrous scarring with small amounts of
    non-refractile foreign material present), omental mass (focal
    interstitial hemorrhage and focal subserosal fibrosis), right pelvic
    sidewall cyst (hemorrhagic cyst with hemosiderine and fibrosis),
    anterior pelvic wall cyst (granuloma to old refractile suture material).
    There was also extensive lysis of adhesions due to previous surgeries.

    My first thought was 49203 but I'm not entirely comfortable with it based on the pathology. Then there is the vaginal cuff mass. Any opinions welcome.
    Angela Jordan, CPC, COBGC, AAPC Fellow
    Senior Managing Consultant
    Medical Revenue Solutions, LLC
    AAPC National Advisory Board - Southwest
    AAPCCA BOD Chair 2012-2013

  2. #2
    To bill 49203 you need to have the size of the mass or tumor as these sets of codes explain.

    L.Ivonne Garcia CPC
    TUcson, AZ

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