tci General Surgery Coding Alert - 2014 Issue 9

You Be the Coder: Don't Forget Surgical Approach Documentation

Question: A patient had a malignant neoplasm of abdomen with obstruction and recurrent incisional hernia. The surgeon performed a needle core biopsy of a retroperitoneal mass, as well as a resection and anastomosis of the small intestine that involved an ileostomy, as well as a repair of the incisional hernia. How should we code the case?  SuperCoder Subscriber Answer: The question is difficult to answer because you don’t describe the surgical approach, and the surgeon may have performed the procedure either laparoscopically or as an open procedure.    Assuming that this is an open procedure, you...

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