Wiki Need CPT help with this surgery

Jwitkop1

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Gaylord, MI
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Preop Diagnosis: #1 Post op day 3 from robotic cholecystectomy
#2 Bile leak

Postop Diagnosis: Bile leak

Operation performed: Diagnostic laparoscopy with washout drain placement.

Description of Procedure: Patient was taken to operating room & general anesthesia was induced per the department. The checklist was complete.
Prior laparoscopic ports were reopened using 15 blade scalpel. Optiview trocar was inserted under direct relation. Abdomen insufflated CO2. Inspected abdomen. There was a small amount of bile in the right upper quadrant. The abdomen was copes irrigated. Hemostasis maintained. There is no instantly adjacent organ injury. There was omentum that was stuck to the gallbladder fossa. I did not remove this. A 10 flat Jackson-Pratt drain was placed in the upper quadrant & brought out the right lateral port. It was secured to the skin using 3-0 nylon. All skin lesions were closed with interrpted 4-0 monocryl. Dermabond was then applied top skin.
 
PER CMS

A diagnostic laparoscopy includes “washing,” infusion, and/or removal of fluid from the body cavity. A provider/supplier shall not report CPT codes 49082-49083 (Abdominal paracentesis) or 49084 (Peritoneal lavage) for infusion and/or removal of fluid
from the body cavity performed during a diagnostic or surgical laparoscopic procedure.

Drains are inclusive for the abdominal procedure.

I would use 49320.
 
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