General Surgery Coding Alert
Finalize Dx from Pathology
Question: Our surgeon performed a retroperitoneal exploratory laparoscopic surgery with a biopsy of a right-lumbar lymph node mass. What procedure and diagnosis codes should we use? Texas Subscriber Answer: With the information you provided, the best option for the procedure code appears to be 49321 (Laparoscopy, surgical; with biopsy (single or multiple)). Regarding the diagnosis, remember that it is always best to wait for the pathology report and list the final diagnosis. Because you don’t provide final diagnosis information, the only option you have is some kind of non-specific code such as I89.9 (Noninfective disorder of lymphatic vessels and lymph nodes, unspecified) or D48.3 (Neoplasm of uncertain behavior of retroperitoneum), depending on the surgeon’s impression.
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