tci General Surgery Coding Alert - 2019 Issue Q4

Reader Question: Symptoms May Lead New Dx Choice

Question: The surgeon performs a diagnostic laparoscopy for a patient who has undergone past endometrial ablations and suffers cyclic pelvic pain and hematometra. What diagnosis and procedure codes should we use? Texas Subscriber Answer: The correct procedure code is 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)). If you don’t have a diagnosis from the laparoscopy report and/or a pathology exam, you may assign a code based on the narrative diagnosis, such as cyclic pelvic pain (R10.2, Pelvic and perineal pain) and hematometra (N85.7, Hematometra)...

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