General Surgery Coding Alert

If your surgeon must return a patient to the operating room for abdominal washout due to complication, don't select lavage code 49080 uncritically. In many cases, the procedure will qualify for a more extensive (and higher-valued) exploratory laparotomy.

Surgeons will use the term "lavage" to describe washing out of abdominal wounds during an exploratory surgery, but you should be careful not to confuse this with lavage as defined by 49080 (Peritoneocentisis, abdominal paracentisis, or peritoneal lavage [diagnostic or therapeutic]; initial).

During peritoneal lavage (49080) the surgeon introduces a saline solution into the peritoneal cavity through a catheter inserted through the abdominal wall (peritoneocentesis), then drains and collects the fluid. This fluid undergoes analysis for blood, chemical, or microscopic findings to diagnose, for instance, intra-abdominal trauma.

"We use diagnostic peritoneal lavage in the trauma room and emergency department all the time when we are trying to evaluate an abdominal or thoracic injury," notes John F. Bishop, PA-C, CPC, MS, CWS, president of Tampa, Fla.-based Bishop & Associates. "We insert the peritoneal trocar and needle, frequently in the umbilicus, and flood in the saline looking for a backwash of blood, clots, tissue bits or infection fluid."

To perform this procedure, the surgeon makes a small incision over the abdomen and inserts a catheter through which to introduce and withdraw the solution. Like peritoneocentesis or abdominal paracentisis, which involves draining fluid from the abdominal cavity, peritoneal lavage is a simple procedure requiring only local anesthetic.

Key point: "Code 49080 does not involve opening the abdomen," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians (UWP) and Children's University Medical Group (CUMG) Compliance Program.

"This is a great example of how fixating on a single term [lavage], or failing to read the entire operative report, can lead to mistakes," Bucknam continues.

If the surgeon documents "lavage" in the operating room, you should not treat this washing or cleansing as the primary procedure. Rather, the lavage is only a component of a more extensive procedure, usually an exploratory laparotomy, and typically consists of dumping saline solution into the open peritoneal cavity. The surgeon removes the fluid by suction, also irrigating out blood or intraperitoneal contaminants.

Exploratory laparotomy is a major procedure, with the patient under general anesthesia in an operating room. This may occur following trauma, for instance, or to treat post-operative complications such as infection.

In such cases, "the correct coding is 49000 [Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure)] or 49002 [Reopening of recent laparotomy]," Bucknam explains. "The actual lavage, or washing, is a bundled component of the exploratory laparotomy."

"This is often miscoded," Bucknam continues. And, as she points out, if you select 49080 when either 49000 or 49002 is the better choice, "The revenue loss is substantial."

"I definitely agree that you should carefully read the entire operative note to get the maximum for CPT coding and reimbursement," Bishop adds.

Example: CMS assigns 1.35 physician work relative value units (RVUs) to 49080, but 12.44 RVUs for 49000 and 17.55 RVUs for 49002. Choosing the wrong code (that is, 49080 when either 49000 or 49002 is appropriate, or 49000 when 49002 is appropriate), therefore, can cost your surgeon from nearly $200 to over $700, based on national average reimbursement rates for Medicare.

Note that you will not report 49000 separately when exploratory laparotomy occurs prior to or with another abdominal surgery. CPT lists 49000 as a "separate procedure." Under AMA guidelines as outlined in the CPT Assistant, Fall 1992, separate procedures "are commonly carried out as an integral part of a total service, and as such do not warrant a separate identification."

Only when a separate procedure "is performed

independently of, and is not immediately related to, other services," may you claim it. "Thus, when a procedure that is ordinarily a component of a larger procedure is performed alone for a specific purpose, it may be considered to be a separate procedure," the AMA concludes.

For instance, if the surgeon opens the abdominal cavity to perform partial colectomy (for instance, 44140, Colectomy, partial; with anastomosis) you would include the laparotomy as part of the colectomy. You would not report 49000 separately with 44140.