Internal Medicine Coding Alert

Question: A patient complains of pain in the right lower quadrant, and an appendectomy is performed. Upon evaluation of the appendectomy, no inflammation or abnormalities are identified. What is the appropriate CPT code for this situation?

Michigan Subscriber

Answer: Report code 44950 (appendectomy) if the surgeon removed the appendix even though there was no indication of inflammation or other abnormality, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services Inc., a medical practice consulting firm in Broomfield, Colo. If the surgeon did not excise the appendix, code 49000 (exploratory laparotomy) may be more appropriate.

If the appendectomy was performed in addition to other surgical procedures, the coding could change. Code 44955 (appendectomy; when done for indicated purpose at time of other major procedure) should be used to report an appendectomy performed in addition to other surgery. An exploratory appendectomy performed at the time of other abdominal procedures is usually not reimbursed separately.