CPT Knowledgebase - Dec 25, 2019

When an incision is extended during a laparoscopic procedure to remove the specimen, should a code for a laparoscopic or open procedure be reported? In this instance, a patient with a persistent right ovarian dermoid cyst presented for removal of the cyst. The mass was transected from its pedicles. An endobag was placed, but the mass was too large, so the decision was made to extend the trocar incision on the right side by 12 mm. The incision was carried down to the fascia, and the rectus muscles were transected and the peritoneum was entered, allowing the mass to be grasped and brought through the abdominal incision.

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