CPT Code For Diagnostic Laparotomy

CPT Code For Diagnostic Laparotomy (2022) Description, Guidelines, Reimbursement, Modifiers & Examples

CPT code for diagnostic laparotomy is also known as exploratory laparotomy, and the CPT code used for both is 49000. First, the surgeon makes a large incision into the patient’s abdomen. Then, an exploratory laparotomy is done to diagnose the cause of problems like abdominal pain, bleeding, and therapeutics of the abdominal region.

CPT Code For Diagnostic Laparotomy Description

This service (CPT 49000) is often performed when an abdominal injury occurs in an accident and needs emergency medical care. If the physician finds something during the procedure (CPT code for diagnostic laparotomy 49000), it leads to treatment of the effective site.

The following organs are included in exploratory laparotomy:

  • Lymph nodes
  • Liver
  • Appendix
  • Spleen
  • Gallbladder
  • Large Intestine
  • Ovaries
  • Stomach
  • Kidney
  • Abdominal Blood vessels and Membranes
  • Pancreas
  • Small intestine
  • Ovaries
  • Uterus
  • Fallopian tubes

The CPT 49000 procedure is done by scope to explore organs and structure by making a large incision above the pubic hairline to the rib cage.

The physician can systematically visualize the abdominal cavity to examine all abdominal organs. This service (CPT 49000) is integral to a more complex procedure and cannot be billed separately.

It can only be reported when done alone or with any unrelated work combined with CPT 49000.

The appropriate modifier will be required when done in conjunction with other procedures.

For example, if a patient got a gunshot wound and physicians explored the wound without a laparotomy due to a penetrating injury, then CPT 20102 would be reported instead of CPT 49000.

If any recent laparotomy was done on the patient and required reopening, CPT 49002 will be reported instead of 49000. In addition, CPT 49010 will be billed for exploring the peritoneal organs.

CPT code for diagnostic laparotomy 49000 is done to explore the abdominal cavity with the aid of the scope. This procedure can also be done by taking a tissue sample. This CPT 49000 surgical procedure includes:

  • Exploratory Laparotomy
  • Celiotomy (Exploratory)
  • With or without biopsy

CPT 49002 will be reported when reopening the recent laparotomy. It is normally reopened to treat bleeding or postoperative infection at the existing laparotomy site.

diagnostic laparotomy cpt code

CPT Code For Diagnostic Laparotomy Coding Guidelines

The billing guidelines for CPT code for diagnostic laparotomy 49000 can be found below.

The 49000 CPT code is not separately reportable if any open abdominal procedure is done in conjunction with exploratory laparotomy.

Open abdominal procedures are included or routinely performed under CPT 49000. 

CPT code for diagnostic laparotomy 49000 is not allowed to be billed together with CPT 49402 (Foreign body removal from the peritoneal cavity), and the modifier is also not allowed according to NCCI. Therefore, only one procedure will be payable.

For instance, if a patient gets a bullet into the peritoneal region and the physicians decide to have surgery, they remove the bullet from the patient’s body and do an exploratory laparotomy (CPT 49000). Therefore, CPT code for diagnostic laparotomy 49000 will not be reported in that case. 

Suppose physicians reopened a laparotomy (CPT 49002) during the postoperative period at the exiting laparotomy site.

According to NCCI, CPT code 49002 will be reported alone and cannot be billed with the 49000 CPT code.

If a physician reopens a laparotomy with adhesion lysis (CPT44005), then CPT 49002 is separately reportable.

CPT code 44005 is a more extensive and complex procedure than laparotomy. Therefore, CPT 44005 alone will be reported.

The 49014 CPT code (Exploration of the pelvic wound with pelvic removal packing) is allowed to bill with CPT 49002, and CPT 49000 and modifier are allowed according to NCCI. However, CPT 49002 and 49000 cannot be billed together.

CPT Code For Diagnostic Laparotomy With Abdominal Washout

When the CPT code for diagnostic laparotomy 49000 is done in conjunction with abdominal washout (CPT 49084), both services are allowed to be billed together on the same day. No modifier will be required to report these CPTs.

CPT Code For Diagnostic Laparotomy With Partial Omentectomy

When the CPT code for diagnostic laparotomy 49000 or reopened laparotomy (49002) is billed with partial omentectomy (CPT 49255).

It would be considered a secondary procedure (CPT 49255) and cannot be billed on the same day as CPT 49000 or CPT 49002. A modifier is also not allowed to be appended to CPT 49255.

CPT Code For Diagnostic Laparotomy With Control of Bleeding

The procedure includes control of bleeding (CPT 44378), which is included in the procedure (CPT 49000) and is not separately reportable.

But this code can be applied if the patient returned in the postoperative period for control of bleeding, then it would be reportable with Modifier 78.

If the physician reopens the laparotomy at the incision site to control bleeding, CPT 49002 will be billed alone.

CPT Code For Diagnostic Laparotomy With Tumor Debulking

If CPT codes 58957-58960 are billed for tumor bulking when these codes are billed together as Exploratory Laparotomy (CPT 49000), then laparotomy will be secondary to tumor debulking.

CPT code for diagnostic laparotomy 49000 is not allowed to be billed together with tumor debulking codes (CPT 58957–58960), and the modifier is also not allowed according to NCCI. Therefore, only CPT 58957–58960 will be reported due to higher RUVS or payments. 

Diagnostic Laparotomy Reimbursement

The total RUVS of 49000 CPT code for diagnostic laparotomy and the cost are listed in the table below as per current rates:

Facility – 24.11368 – $834.48

Non-Facility-24.11368 – $834.48

CPT Code For Diagnostic Laparotomy Modifiers

The CPT code for diagnostic laparotomy has a global period of 90 days. 

The following are common modifiers:

Modifier 22 is used when the procedure takes longer than regular procedural services.

Modifier 47 is used when the physician gives anesthesia to the patient that is not usually required.

Modifier 51 is used when multiple procedures are performed at a time.

In some circumstances, modifier 52 is used when some circumstances’ procedure is partially reduced. 

Modifier 53 is used when the surgical or diagnostic procedure is discontinued after starting the procedure due to some circumstances.

When this procedure is performed in a global period, modifier 58 is used. It may be staged or related to a procedure or service by the same physician or other QHC professionals during the postoperative period.

Modifier 59 is used when other distinct procedural services are performed other than E/M

Modifier 78 is used when a patient has an unplanned return to the operating room by the same physician following the initial procedure for a related procedure during the postoperative period. 

Modifier 79 is used when a patient has an unrelated procedure or service by the same physician or another QHC professional during the postoperative period.

Other than these modifiers, 23, 54, 55, 56, 58, 62, 63, 76, 77, 80, 82, 81, 99, AI, AQ, AR, AS, CC, CR, ET, EY, GA, GC, GJ, GK, GR, GU, GY, and modifier GZ is also used with the CPT code for diagnostic laparotomy.

CPT Code For Diagnostic Laparotomy Examples

There are the following examples of when the CPT code for diagnostic laparotomy will be billed:

Example 1 

A 65-year-old female with PMH non-insulin-dependent type 2 diabetes presents with severe lower abdominal pain and no urination since 11 pm 10/7/21.

She reports that she had a PAP smear earlier today and has had a pessary. The pessary was replaced after the procedure yesterday afternoon.

Afterward, she reports no urination and abdominal distension/tenderness/pain. Again, this has never happened before.

She denies fevers, chills, headaches, changes in vision, chest pain, palpitations, SOB, n/v/d/c, arm or leg pain, numbness, and tingling. The exam, CT, and MRI revealed abnormal findings. The physician decides to do a surgical procedure called an exploratory laparotomy.

Example 2

A 29-year-old male with PMH obesity presents a lump in the peritoneal region to the ED. He reports that his pain is worsening daily, and today, around 4 pm, he fell 10/10 in the left lower quadrant.

When he took some pain medication, the issue was not resolved. He reports that he suffers from anxiety and wants to get it checked out.

He denies fevers, chills, headaches, neck pain, ear pain, lightheadedness, dizziness, chest pain, palpitations, SOB, n/v/d/c, dysuria, hematuria, or arm/leg pain.

The physician did not find anything on the exam, but the patient’s situation worsened, and they planned to do an exploratory laparotomy.

Example 3

A sixty-six-year-old male with no significant medical history presented to the ER with generalized abdominal pain, diarrhea, and vomiting.

Per the patient, he has had cold and flu-like symptoms for approximately two weeks. As a result, he was given ABX, azithromycin, and cefuroxime by his PCP, Dr. Akbar. He took the meds for six days without issue.

Physical exam remarkable by cough, wheezing on bilateral lungs, normotensive, patient tachycardic to 136, afebrile, pt in NA Last night, I awoke with the sensation of acute abdominal pain and sweating.

He had three episodes of SX, including when he woke up this AM. Otherwise, deny CP, SOB, vomiting, fevers, or chills. Unfortunately, the physician could not diagnose his problem and decided on the surgical procedure for the abdomen.

Example 4 

The patient is a sixty-five-year-old male with PMH anterior cervical discectomy, also known as lumbar stenosis, and L shoulder surgery.

He is presenting with 1.5 weeks of left lower quadrant pain. He says it is moderate and has worsened, but it has stayed for a prolonged period, prompting the ER visit.

The pain seems to be triggered after getting medication for pain, and the patient had blood in his vomit. The pain is moderately severe.

Curious diagnostic tests were ordered, and a study revealed that surgical exploratory laparotomy would be needed.

Example 5

A 29-year-old male presented to the ER after a motor vehicle accident and was severely injured. He had abdominal, neck, head, and fractured left foot injuries. In addition, he has severe abdominal bleeding that needs urgent treatment.

Pt has had vision changes, weakness, numbness, and tingling. f/c, cp, sob, NVD, abdominal pain, dysuria, hematuria.

Bleeding was not stopped after medications and treatment. So, the physician did an exploratory laparotomy to control the bleeding. 

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