Gastroenterology Coding Alert

Question: My physician performed an open inguinal hernia repair on an  infant (49491). She also performed a diagnostic laparoscopy and found a left inguinal hernia. Can I code 49320 for the diagnostic laparoscopy? My first thought was that it would be included in the surgery, but don't see an edit saying they cannot be coded together. Any advice?

Wyoming Subscriber

Answer: You should simply refer to NCCI guidelines for Surgery: Digestive System (CPT® Codes 40000-49999). Here's an excerpt on the laparoscopy section of the guidelines that can help you tackle your problem:

1. Surgical laparoscopy includes diagnostic laparoscopy which is not separately reportable. If a diagnostic laparoscopy leads to a surgical laparoscopy at the same patient encounter, only the surgical laparoscopy may be reported.

2. If a laparoscopy is performed as a "scout" procedure to assess the surgical field or extent of disease, it is not separately reportable. If a diagnostic laparoscopy leads to the performance of an open procedure, the diagnostic laparoscopy may be separately reportable. Modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) may be reported to indicate that the diagnostic laparoscopy and non-laparoscopic therapeutic procedures were staged or planned procedures. The medical record must indicate the medical necessity for the diagnostic laparoscopy.