# abdominal wall exploration



## lindacoder (Aug 13, 2010)

Patient was felt to have an epigastric hernia. OP reads as follows:

Abdomen was prepped and draped in a standard surgical fashion. I then proceeded to infiltrate local anesthetic at the site that had been premarked. This was about 2 cm above the umbilicus. Vertical incision was made about 3 cm in length using a 15 blade. Dissection was then carried sharply down to the subcutaneous fat down to the level of the fascia and I proceeded to clear all the fat off the fascia along the midline. At this point, I was not able to identify any evidence of a fascial defect. I proceeded superiorly a little bit further as well as inferiorly down to the umbilicus again. I was not able to defect any fascial defect. Once this was confirmed, I then proceeded to control for hemostasis. The wound was then closed in a two-layered fashion using a running 3-0 Vicryl stitch to reapproximate the deep tissue layers and a running 4-0 Monocryl subcuticular stitch to reapproximate the skin edges. 

If I use 49570 with a 52 modifier would that be correct?  Also what kind of diagnosis code would I use?

Thanks


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## preserene (Aug 13, 2010)

HERNIA A HERNIA is a protrusion of an internal organ or part of an organ through a tear, hole or defect in the wall of a body cavity (ie the abdominal wall muscle)- meaning the rectal facsia andthe abdominal Rectus muscle all shd have been weaked and the abdominal contents atleast the peritoneum should have been herniating through the defect. 
The surgeon did not  cut through more than the fatty tissues( a kind of removal of the fatty tissues  to visualize the fascia)  and did not find a defect.
This was a sort of negative herniorraphy. He would have found a sort of protrusion which contemplated for surgery. This can happen with female obese patients -a kin dof ventral /epigastric hernia like symptoms. 
As you said, there is no code for abddominal wall exploration but for FB removal, debriments which do not fit for our case under discussion

well, the diagnostic code ICD-9 Vcode would help to support: V71x (V71.8 the 'evaluation' part being the 'exploration') which can be first listed diagnosis code ; CPT code: as you said ventral / epigastric hernia Repair code with reduced services. Payers may not accept this.

 For discussion perspectives, can I suggest some more?!

The  Repair code - Intermediate Repair be assigned ( taking it for granted this being a 'suspected wound from within' ??
 Or Wound exploration, penetration- taking it as 'suspected penetration from within' ??!!. then you have a code for this too!! Just a sort of kidding suggestion please; some times may click!

My sincere suggestion is for a CPT code as you contemplated with a modifer for reduced service, with Diag code V 71.8. which can be first listed with a detailed procedural report from the surgeon.
If the payer pass it on , we are off the hook. 
if not, let us  try for the Repair code.
Thank you for reading


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