How To Use CPT Code 49002

CPT 49002 describes the reopening of a recent laparotomy, which is the surgical incision into the abdomen. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 49002?

CPT 49002 can be used to report the reopening of a recent laparotomy, which involves making an incision through a previous abdominal incision to check for complications such as internal bleeding or infection. This procedure is performed by a healthcare provider when there is a need to examine the organs and structures in the abdomen for any signs of complications.

2. Official Description

The official description of CPT code 49002 is: ‘Reopening of recent laparotomy.’

3. Procedure

1. The healthcare provider prepares and anesthetizes the patient.
2. An incision is made through the previous abdominal incision.
3. The provider examines the organs and structures in the abdomen for evidence of infection or bleeding.
4. If necessary, the provider ties off any bleeding vessels and takes cultures from potential sites of infection.
5. The provider may drain fluid from the abdomen or perform lavage, washing out the abdominal cavity with water or saline solution.
6. The wound is irrigated, checked for bleeding, any instruments are removed, and the incision is closed.

4. Qualifying circumstances

CPT 49002 is used when a healthcare provider reopens a recent laparotomy to check for complications such as internal bleeding or infection. This procedure is typically performed when there are indications of complications, such as fever or signs of bleeding, and is not planned in advance. Modifier 78, Unplanned return to the operating or procedure room by the same provider following initial procedure for a related procedure during the postoperative period, should be applied in these circumstances.

5. When to use CPT code 49002

CPT code 49002 should be used when a healthcare provider reopens a recent laparotomy to check for complications. It should not be used for planned re-exploration or when the abdomen is entered only to perform lavage. Modifier 78 should be applied when the return to the operating room is unplanned and occurs during the postoperative period.

6. Documentation requirements

To support a claim for CPT 49002, the healthcare provider must document the following information:

• Reason for reopening the recent laparotomy
• Details of the procedure performed, including any findings or complications
• Date and time of the procedure
• Any additional treatments or interventions performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 49002, ensure that the reopening of the recent laparotomy is performed by the same provider who performed the initial procedure. Modifier 78 should be applied to indicate an unplanned return to the operating room during the postoperative period. It is important to note that CPT code 49002 is an inpatient-only procedure.

8. Historical information

CPT 49002 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient undergoes a laparotomy for appendectomy. A few days later, the patient develops a fever and abdominal pain. The healthcare provider reopens the recent laparotomy to investigate for possible infection or other complications.
2. Following a laparotomy for bowel resection, the patient experiences persistent bleeding. The healthcare provider reopens the recent laparotomy to identify and address the source of the bleeding.
3. After a laparotomy for tumor removal, the patient develops signs of infection. The healthcare provider reopens the recent laparotomy to obtain cultures and drain any fluid or abscesses present.
4. During a laparotomy for hernia repair, the healthcare provider accidentally leaves a surgical instrument inside the patient. The recent laparotomy is reopened to remove the instrument and ensure no further complications.
5. Following a laparotomy for trauma, the patient’s condition deteriorates with signs of internal bleeding. The healthcare provider reopens the recent laparotomy to identify and control the source of the bleeding.