General Surgery Coding Alert

Question: The surgeon performs a diagnostic laparoscopy for a patient who has undergone past endometrial ablations and suffers cyclic pelvic pain and hematometra. What diagnosis and procedure codes should we use?

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Answer: The correct procedure code is 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)).

If you don’t have a diagnosis from the laparoscopy report and/or a pathology exam, you may assign a code based on the narrative diagnosis, such as cyclic pelvic pain (R10.2, Pelvic and perineal pain) and hematometra (N85.7, Hematometra), and history of endometriosis (Z87.42, Personal history of other diseases of the female genital tract).

New: This case may be a patient with post endometrial ablation syndrome, which typically includes symptoms such as cyclic pelvic pain and retention of blood in the uterus (hematometra). You should be aware of the following new diagnosis code that reflects the condition, says Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, New Mexico: N99.85 (Post endometrial ablation syndrome). You may want to consult the clinician who requested the procedure to determine if N99.85 (effective Oct. 1, 2019) or symptom codes, such as those previously mentioned, are the most appropriate for this case.