How To Use CPT Code 49402

CPT 49402 describes the surgical procedure of removing a foreign body from the peritoneal cavity. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 49402?

CPT 49402 can be used to describe the surgical removal of a foreign body from the peritoneal cavity. This code is used when a provider makes an incision in the abdominal wall to visualize and remove the foreign object. The procedure involves evacuating blood and clots, washing out the abdomen, identifying and removing the foreign body using sharp and blunt dissection and hemostats, achieving hemostasis, and closing the wound in layers.

2. Official Description

The official description of CPT code 49402 is: ‘Removal of peritoneal foreign body from peritoneal cavity.’

3. Procedure

1. The provider makes an incision in the abdominal wall to visualize the area of concern.
2. Once inside the abdomen, the provider evacuates blood and clots and performs a lavage to identify any points of bleeding or disease.
3. The provider identifies and removes the foreign body using sharp and blunt dissection and hemostats.
4. Hemostasis is achieved to stop any bleeding.
5. The provider removes any instruments and closes the wound in layers.

4. Qualifying circumstances

CPT 49402 is performed when there is a foreign body within the peritoneal cavity that needs to be removed. The procedure is typically done under anesthesia and requires the provider to have good visualization of the abdominal cavity. The patient must be appropriately prepped and anesthetized for the procedure.

5. When to use CPT code 49402

CPT code 49402 should be used when a provider surgically removes a foreign body from the peritoneal cavity. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the procedure involves lysis of intestinal adhesions, a different code (44005) should be used. Other codes may be more appropriate for open or percutaneous peritoneal drainage or lavage, or for percutaneous insertion of a tunneled intraperitoneal catheter without a subcutaneous port.

6. Documentation requirements

To support a claim for CPT 49402, the provider must document the following information:

• Reason for the procedure and the presence of a foreign body in the peritoneal cavity
• Details of the surgical procedure, including the incision, evacuation of blood and clots, lavage, identification and removal of the foreign body, achievement of hemostasis, removal of instruments, and closure of the wound
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 49402, ensure that the procedure meets the specific criteria outlined in the code description. It is important to use the appropriate code based on the specific circumstances of the procedure. CPT code 49402 should not be reported if other related codes (such as 49406, 49020, 49040, 49082-49084) have already been performed in the previous seven days. Consider the location of the testing when coding for peritoneal procedures.

8. Historical information

CPT 49402 was added to the Current Procedural Terminology system on January 1, 2007. There have been no updates to the code since its addition.

9. Examples

1. A surgeon removing a foreign body, such as a piece of broken surgical instrument, from the peritoneal cavity during a surgical procedure.
2. A provider removing a retained surgical sponge from the peritoneal cavity after a previous surgery.
3. A gastroenterologist removing a swallowed foreign object, such as a coin or small toy, from the peritoneal cavity using endoscopic techniques.
4. A trauma surgeon removing a bullet or other foreign object from the peritoneal cavity after a gunshot or stab wound.
5. A gynecologist removing an intrauterine device (IUD) that has migrated into the peritoneal cavity.
6. A urologist removing a migrated kidney stone from the peritoneal cavity using minimally invasive techniques.
7. A pediatric surgeon removing a swallowed magnet or other foreign object from the peritoneal cavity of a child.
8. An oncologist removing a tumor or metastatic lesion from the peritoneal cavity during a cancer surgery.
9. A general surgeon removing a piece of necrotic tissue or abscess from the peritoneal cavity to treat an infection.
10. A vascular surgeon removing a migrated stent or embolization coil from the peritoneal cavity using endovascular techniques.