General Surgery Coding Alert

Question: How should I code an exploratory laparotomy with excision of a large liver cyst (10 cm x 3 cm) in a newborn?

South Carolina Subscriber

Answer: Correct coding for this procedure will depend on some factors that you don't specify in your question. After studying the following options, you should go back to your op report and see if you can narrow down the choices.

If the surgeon performed a partial lobectomy, the proper code would be 47120 (Hepatectomy, resection of liver; partial lobectomy). This seems the most likely code choice because the documented cyst is very large for a newborn, and because you state that the surgeon performed an excision.

If the treatment was not a liver excision, however, but was directed only at the cyst, a better code choice might be 47010 (Hepatotomy; for open drainage of abscess or cyst, 1 or 2 stages). If none of the current listed codes describe what the op note says, you might need to use the unlisted liver code (47399, Unlisted procedure, liver).

If the newborn patient is a tiny premature baby, you might be able to use modifier 63 (Procedure performed on infants less than 4 kgs). You should not use modifier 63 on the unlisted code (47399).