Part B Insider (Multispecialty) Coding Alert

Question: Our gastroenterologist recently performed a laparoscopic procedure on a patient with lymphoid hyperplasia of the lateral aspect of the cecum. He used electrocautery to excise hypertrophic lymph nodes of the folds. The excised tissue was sent to pathology for study. Can you please let me know how I should report the procedure as I am not seeing any relevant code for this procedure under laparoscopic procedures for the lymphatic system?

Answer: As you have rightly indicated, there is no specific CPT® code to describe a laparoscopic excision of the lymphatic tissue using electrocautery. Since there is no specific code for the procedure, you will have to settle down with reporting 38589 (Unlisted laparoscopy procedure, lymphatic system).

Since you're reporting an unlisted code, you will have to provide documentation explaining in detail about the procedure that your gastroenterologist performed also providing information on the time involved in carrying out the procedure. Also, provide an explanation indicating that you have performed a thorough search in the 2012 CPT® manual and found no procedure code that matches to the procedure that your gastroenterologist performed. Explain that as you could find no code, you had to settle in for the unlisted code for the procedure.