Exploratory Laparotomy CPT Code 49000 | Description, Guidelines, Reimbursement & Clinical Examples

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, it leads to treatment of the effective site.

Exploratory Laparotomy CPT Code | Description & Explanation

The official description of the Exploratory Laparotomy CPT code 49000 is: “Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure).”

The following organs 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 visualize the whole abdominal cavity to systematically examine all abdominal organs. This service is integral to 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 code 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 explored the wound without Laparotomy due to a penetrating wound, then CPT 20102 would be reported instead of the 49000 CPT code.

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

CPT code 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 surgical procedure includes:

• Exploratory Laparotomy
• Exploratory Celiotomy
• With or without a biopsy

Modifiers

Suppose any unrelated procedure is combined with the CPT code for Exploratory laparotomy. Then modifier 59 is appropriate to append with CPT 49000.

Modifier 58 is applicable with CPT 49000 when physicians plan to do the procedure again or a part of the procedure during the postoperative 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 postoperative period. In this case, 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 code 49000 and cost is listed in the table below as per current rates:

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

Billing Guidelines

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

The 49000 CPT code is not separately reportable if any open abdominal procedure is done with exploratory laparotomy. The 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 surgery to remove the bullet from the patient’s body and also do Expolatorey Laparotomy (CPT 49000).

Suppose physicians have reopened Laparotomy (CPT 49002) during the postoperative 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 with adhesions lysis (CPT 44005), 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 CPT code (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 codes.

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 as 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 (CPT 44378) is included in the surgery (CPT 49000) and is not separately reportable.

But this code can be applied if the patient returns in the postoperative period for bleeding control, 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, 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

The following are examples of when Exploratory Laparotomy will be billed with CPT 49000.

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, and tingling. The exam, CT, and MRI revealed abnormal findings. The Physician decides to do a surgical procedure Exploratory Laparotomy.

Billing:

Patient: 65-year-old female

Diagnoses:

• ICD 10 E11.9: Type 2 diabetes mellitus without complications (Non-insulin-dependent Type 2 Diabetes)
• ICD 10 R10.30: Lower abdominal pain, unspecified (severe lower abdominal pain)
• ICD 10 R33.9: Retention of urine, unspecified (no urination)
• ICD 10 Z97.5: Presence of (functional) urinary catheter (pessary)

Procedures:

• E/M Code (e.g., 99281-99285): Emergency Department visit (determine the appropriate level based on medical documentation)
• CPT 74150, CPT 74160, or CPT 74170: CT abdomen (depending on whether it was performed without contrast, with contrast, or both)
• CPT 72195, CPT 72196, or CPT 72197: MRI pelvis (depending on whether it was performed without contrast, with contrast, or both)

Surgical Procedure:

CPT 49000: Exploratory laparotomy

Example 2

A 29-year-old male with PMH obesity presents to the ED with a lump at the peritoneal region. He reports that his pain is getting worse daily, and today around 4 pm felt pain 10/10 on 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, headache, neck pain, ear pain, lightheadedness, dizziness, chest pain, palpitations, SOB, n/v/d/c, dysuria, hematuria, and arm/leg pain.

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

Billing:

Patient: 29-year-old male

Diagnoses:

• ICD 10 E66.9: Obesity, unspecified
• ICD 10 R22.2: Localized swelling, mass, and lump, trunk (lump at the peritoneal region)
• ICD 10 R10.32: Left lower quadrant pain (left lower quadrant pain)
• ICD 10 F41.9: Anxiety disorder, unspecified

Procedures:

• E/M Code range 99281-99285: Emergency Department visit (determine the appropriate level based on medical documentation)
• CPT 49000: Exploratory laparotomy

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.

Billing:

Patient: 66-year-old male

Diagnoses:

• ICD 10 R10.84: Generalized abdominal pain
• ICD 10 R19.7: Diarrhea, unspecified
• ICD 10 R11.2: Nausea with vomiting, unspecified
• ICD 10 J00: Acute nasopharyngitis [common cold]
• ICD 10 R05: Cough
• ICD 10 R06.2: Wheezing
• ICD 10 R00.0: Tachycardia, unspecified

Procedures:

• E/M Code range 99281-99285: Emergency Department visit (determine the appropriate level based on medical documentation)
• CPT 49000: Exploratory laparotomy