# Open procedure and Laproscopic - which codes?



## jdibble (Feb 25, 2016)

I am having issues figuring out the correct codes for this surgery - any help would be appreciated! The surgeon wants to code 49320 and 48100.  I agree with the 48100 however I do not believe 49320 is the correct code. It appears he did an exploratory lap, then made an incision to perform the pancreas and lymph node biopsy. So I see the 48100, however I am not sure what other codes I can use for the lymph node biopsies.

PREOPERATIVE DIAGNOSIS:  Carcinoma of the pancreas.

POSTOPERATIVE DIAGNOSIS:  Carcinoma of the pancreas, with superior mesenteric lymph nodes.

OPERATION:  Laparoscopy, Laparotomy, Exploration of retroperitoneum, multiple lymph node biopsies and open pancreatic biopsy.

ANESTHESIA:  General endotracheal.

ESTIMATED BLOOD LOSS:  100 ml.

DRAINS:  Foley catheter, nasogastric tube and large, round Jackson-Pratt drain to retroperitoneum.

FINDINGS:  Negative laparoscopy.  However, at the time of laparotomy and exploration of the retroperitoneum, there was metastatic adenopathy to the nodes along the superior mesenteric artery, just as they passed through the pancreas, in which there was a large pancreatic mass in the body that appeared to be away from the artery and vein and not fixed.  This was cystic in nature and biopsied.
The patient had nodular cirrhosis consistent with alcoholic cirrhosis.

COMPLICATIONS:  None.

PROCEDURE IN DETAIL:  The patient was taken to the operating room.  After the induction of satisfactory general endotracheal anesthesia, was prepped and draped in the usual sterile fashion in the supine position.  A Veress needle was used to attain pneumoperitoneum at the level of the umbilicus, followed by a 5 mm optical trocar.  5 mm trocars were placed in the right middle and left middle quadrants.  Exploratory laparoscopy showed no evidence of liver metastases or abdominal carcinomatosis.  The mesentery and the omentum were closely examined as was the stomach and it appeared to be negative for tumor.  At this point, an extended left subcostal incision was created and the abdomen was entered.  The lesser sac was then entered and the colon was swept inferiorly and the stomach superiorly.  The short gastric artery was then taken down using a surgical stapling device.  The pancreas was examined with the above findings.  The lymph nodes of the superior mesentery artery were then biopsied and sent for frozen section, which was consistent with an adenocarcinoma.  At this point, the body of the pancreas was also biopsied and was found to be cystic and solid.  It should be noted that the patient had fairly severe nodular cirrhosis of the liver.  A large, round Jackson-Pratt drain was placed through a separate stab incision, to lie in the bed of the pancreas and the colon was placed back in its anatomic position, as was the stomach and omentum.  The left subcostal incision was closed using two-layer Prolene sutures.  The subcutaneous tissues were closed with #3-0 Vicryl and the skin with a surgical stapling device.  Occlusive bandages were placed.  The patient tolerated the procedure satisfactorily and returned to recovery in stable condition.  All final sponge, instrument and needle counts correct.

Any ideas and your supporting thoughts is appreciated!

Thanks,


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## ltrue (Feb 26, 2016)

*+38747*

I came up with 48100 and 38747.  

Per AAPC Coder Lay Terms: "When the patient is appropriately prepped and anesthetized, the provider incises the abdomen. The provider performs a primary procedure such as a tumor resection first, and she inspects the abdomen. She then excises and removes diseased lymph nodes near the stomach, liver, and pancreas. She may also remove additional nodes near the aorta. In cases of extensive metastatic cancer, it may be necessary to remove all the lymph nodes in the area of the disease. 

The provider then ensures that she controls all bleeding. After the procedure is complete, the provider reapproximates the subcutaneous tissues and closes the incision in layers. The provider may place a drain to remove any fluids during healing."

Let me know if you find something closer!


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## jdibble (Feb 29, 2016)

ltrue said:


> I came up with 48100 and 38747.
> 
> Per AAPC Coder Lay Terms: "When the patient is appropriately prepped and anesthetized, the provider incises the abdomen. The provider performs a primary procedure such as a tumor resection first, and she inspects the abdomen. She then excises and removes diseased lymph nodes near the stomach, liver, and pancreas. She may also remove additional nodes near the aorta. In cases of extensive metastatic cancer, it may be necessary to remove all the lymph nodes in the area of the disease.
> 
> ...



That looks like what I was looking for! Thanks for your help!


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