tci General Surgery Coding Alert - 2022 Issue Q4

Reader Questions: Use This Modifier for Return to OR

Question: Following a recent colectomy, the surgeon had to return to the OR for symptoms of intestinal leakage (purulent drainage, abdominal pain, and fever). The surgeon opened the defect, took swabs and submitted the specimen for culture, performed lavage, and finding no anastomotic leak, closed the site. How should we code this? Virginia Subscriber Answer: The correct code is 49002 (Reopening of recent laparotomy). You should not additionally report the steps you describe, such as lavage (49084, Peritoneal lavage, including imaging guidance, when performed). Because this is an unplanned return to surgery, you should append modifier 78 (Unplanned Return...

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