(2022) Exploratory Laparotomy CPT Code 49000 – Description, Guidelines, Reimbursement & Modifiers

The Exploratory Laparotomy CPT code is 49000. The Physician makes a large incision into the abdomen of the patient.

Exploratory Laparotomy is done to diagnose the cause of problems like abdominal pain, bleeding, and therapeutics of the abdominal region.

This service (CPT 49000) is also done when an abdominal injury occurs in an accident and needs emergency medical care. If the Physician finds something during the procedure (CPT 49000), it leads to treatment of the effective site.

Exploratory Laparotomy CPT Code

There are the following organs that include 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 visualize the whole abdominal cavity for systematic examination of all abdominal organs. This service (CPT 49000) is an integral part of a more complex procedure and cannot be billed separately.

It can be only reported when done alone or any unrelated done in combination 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 have done exploration of the wound without Laparotomy due to penetrating wound, then CPT 20102 would be reported instead of CPT 49000.

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

CPT 49000 is done to explore the abdominal cavity aided by the scope. This procedure can also be done to take a sample of tissues. This CPT 49000 surgical procedure includes:

• Exploratory Laparotomy
• Exploratory Celiotomy
• With or without biopsy

CPT 49002 will be reported when reopening recently Laparotomy done. It is normally reopened to treat bleeding or post-operative infection at the existing laparotomy site.

Modifiers

There is the following list of modifiers that are applicable with CPT 49000: Modifier 22, 23, 47, 51, 52, 53, 54, 55, 56, 58, 59, 62, 63 , 76, 77, 78, 79, 80, 82, 81, 99, AI, AQ, AR, AS, CC, CR, ET, EY, GA, GC, GJ, GK, GR, GU, GY and modifier GZ.

Suppose any unrelated procedure is combined with Exploratory laparotomy CPT(490000). Then modifier 59 is appropriate to append with CPT 490000.

Modifier 58 is applicable with CPT 49000 when physicians plan to do the procedure again or a part of the procedure during the post-operative period on the specified date.

Similarly, when the patient returned to the same physician’s operative room, that was not planned due to some emergency condition like the patient starting abdominal bleeding or severe pain starting during the post-operative period. Therefore, modifier 78 will be appropriate.

Modifier 47 will be attached with CPT 49000 when the Physician gives anesthesia to the patient that is not normally required.  

Reimbursement

The total RUVS of CPT 49000 and cost is listed in the table below as per current rates:

• Facility – 24.11368 – $834.48
• Non-Facility -24.11368 – $834.48

Exploratory Laparotomy CPT Code Billing Guidelines

The billing guidelines for CPT 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.

CPT 49000 services are included or routinely performed in Open abdominal procedures. 

CPT code 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. Only one procedure will be payable.

For Instance, if a patient got a bullet into the peritoneal region and physicians have done surgery to remove the bullet from the patients’ body, and also done Expolatorey Laparotomy (CPT 49000). CPT 49000 will not be reported in that case. 

Suppose physicians have reopened Laparotomy (CPT 49002) during the post-operative period at the exiting laparotomy site.

In that case, CPT code 49002 will be reported alone and cannot be billed with the 49000 CPT code according to NCCI.

If a physician reopens Laparotomy in conjunction with adhesions lysis (CPT44005), then CPT 49002 is separately reportable.

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

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

CPT Code For Exploratory Laparotomy With Abdominal Washout

When exploratory Laparotomy CPT code 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 CPT’s.

CPT Code For Exploratory Laparotomy With Partial Omentectomy

When exploratory laparotomy (CPT code 49000) or Reopened laparotomy (49002) is billed with partial omentectomy (CPT 49255).

It would be considered the secondary procedure (CPT 49255) and cannot be billed on the same day with CPT 49000 or CPT 490002. A modifier is also not allowed to append with CPT 49255.

CPT Code For Exploratory Laparotomy With Control Of Bleeding

Control of bleeding like (CPT 44378) is included in the surgery (CPT 49000) and is not separately reportable.

But this code can be applied if the patient returned in the post-operative 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 Exploratory Laparotomy With Tumor Debulking

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

CPT code 49000 is not allowed to bill together with tumor debulking codes (CPT 58957-58960), and the modifier is also not allowed according to NCCI. Only CPT 58957-58960 will be reported due to higher RUVS or payments. 

Examples

There are the following examples of when Exploratory Laparotomy will be billed:

Example 1 

A 65 yo 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 reports having a pessary. The pessary was replaced after the procedure yesterday afternoon.

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

She denies fevers, chills, headache, changes in vision, chest pain, palpitations, SOB, n/v/d/c, arm or leg pain, numbness, tingling. Exam, CT, MRI revealed abnormal findings. The Physician decides to do a surgical procedure Exploratory Laparotomy.

Example 2

A 29-year-old male with PMH obesity presents a lump at the peritoneal region to the ED. He reports that his pain is getting worse day by day, and today around 4 pm felt pain 10/10 on the left lower quadrant.

When he took some medication for pain and issue did not get resolved. He reports that he suffers from anxiety and just wants to get it checked out.

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

The Physician did not find anything exam, but the patient’s situation is getting worse, and they plan to do an Exploratory laparotomy procedure.

Example 3

Sixty-six-year-old males with no significant medical history presented to ER for Generalized Abdominal pain, diarrhea, Vomiting.

Per patient, he has had cold flu-like symptoms for approx two weeks. He was given ABX, azithromycin, and cefuroxime by his PCP, Dr. Akbar. He took 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 awoke with the sensation of acute abdominal pain and sweating.

He had three such episodes of SX, including when he woke up this AM. Otherwise denies CP, SOB, vomiting, fevers, chills. The Physician was unable to diagnose his problem and decided on the surgical procedure of the abdomen.

Example 4 

The patient is a sixty-five-year-old male with PMH anterior cervical discectomy, known lumbar stenosis, 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.

Pain seems to trigger after getting medication for pain, and the patient had blood in vomit, and the pain is moderately severe.

Physicians order carious diagnostic tests, and a study revealed that Surgical Expalotoy Laparotomy would be needed.

Example 5

A 29-year-old male presented to ER after a Motor Vehicle accident and was severely injured. He had an abdomen, neck, head, and fractured left foot injury. He has severe abdominal bleeding that needs urgent treatment.

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

Bleeding was not getting stopped after medications and treatment. The Physician did Exploratory Laparotomy to control bleeding. 

By Uzair Ali Murtaza
Medical Coding & Billing