How To Use CPT Code 49040

CPT 49040 describes the procedure for drainage of a subdiaphragmatic or subphrenic abscess through an open incision. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 49040?

CPT 49040 can be used to describe the procedure performed by a healthcare provider to drain an abscess located below the diaphragm. The provider makes an incision in the abdomen and removes the infectious material, irrigates the area, and may insert a drainage tube if necessary.

2. Official Description

The official description of CPT code 49040 is: ‘Drainage of subdiaphragmatic or subphrenic abscess, open.’ This code is used when the provider performs an open incision to drain an abscess located below the diaphragm.

3. Procedure

1. The healthcare provider prepares the patient and administers anesthesia.
2. An incision is made in the midline of the abdomen, depending on the location of the abscess.
3. The provider examines the organs and structures to identify the abscess.
4. A culture may be taken for analysis in a laboratory.
5. The provider cleans out the infectious material and irrigates the area with an antibiotic solution.
6. A drainage tube may be inserted to facilitate further drainage.
7. The wound is irrigated, checked for bleeding, and closed or left open for additional drainage.

4. Qualifying circumstances

CPT 49040 is performed when a patient has a subdiaphragmatic or subphrenic abscess that requires drainage. The procedure is typically performed by a healthcare provider in an open surgical setting. The patient must have a documented abscess below the diaphragm, and the provider must determine that drainage is necessary.

5. When to use CPT code 49040

CPT code 49040 should be used when a healthcare provider performs an open incision to drain a subdiaphragmatic or subphrenic abscess. It is important to ensure that the abscess is located below the diaphragm and that the procedure involves an open approach.

6. Documentation requirements

To support a claim for CPT 49040, the healthcare provider must document the following information:

• Patient’s diagnosis of a subdiaphragmatic or subphrenic abscess
• Details of the procedure, including the incision site and size
• Findings during the procedure, such as the identification of the abscess and any cultures taken
• Description of the drainage process and any additional procedures performed
• Details of wound irrigation, closure, or packing
• Any complications or follow-up care required
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 49040, ensure that the procedure meets the criteria for an open drainage of a subdiaphragmatic or subphrenic abscess. It is important to use the appropriate CPT code based on the specific procedure performed. Consider any additional services or procedures provided during the same encounter and follow the appropriate coding guidelines for reporting multiple procedures.

8. Historical information

CPT 49040 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2014, with an updated description. It was also added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A surgeon performing an open incision to drain a subdiaphragmatic abscess in a patient with a documented infection.
2. A gastroenterologist performing an open drainage procedure for a subphrenic abscess in a patient with a history of abdominal surgery.
3. A general surgeon performing an open incision to drain a subdiaphragmatic abscess in a patient with a known abscess on imaging studies.
4. An interventional radiologist performing an open drainage procedure for a subphrenic abscess under image guidance.
5. A surgical team performing an open incision to drain a subdiaphragmatic abscess in a patient with signs of sepsis.
6. A trauma surgeon performing an open drainage procedure for a subphrenic abscess in a patient with a penetrating abdominal injury.
7. A hepatobiliary surgeon performing an open incision to drain a subdiaphragmatic abscess in a patient with a liver abscess.
8. An infectious disease specialist performing an open drainage procedure for a subphrenic abscess in a patient with a history of immunosuppression.
9. A colorectal surgeon performing an open incision to drain a subdiaphragmatic abscess in a patient with diverticulitis.
10. A urologist performing an open drainage procedure for a subphrenic abscess in a patient with a urinary tract infection.