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Code This!

Scenario Week of February 02, 2012:
View Current Scenario

Operative Procedure: The physician makes a small incision in the abdomen, between the umbilicus and the symphysis pubis. After careful dissection guided by ultrasound to ensure the bowel is not perforated, the peritoneum is entered and a catheter is inserted, pointed toward the pelvis. An initial aspiration of peritoneal fluid showed no blood, so an infusion of warm saline was started through the catheter. After five minutes of infusion, the IV bag was lowered to allow for the contents of the bag to return.

The effluent was sent to the lab for analysis. Lab report showed no blood or enteric material in the peritoneal fluid.

Assign the appropriate ICD-9-CM diagnosis codes and the appropriate CPT code(s).

ICD-9-CM Answer:
959.12 Other injury of abdomen>br> E814.7 Motor vehicle collision with pedestrian, injuring pedestrian
E000.9 Other external cause status
E030 Unspecified activity

In this instance, the only valid diagnosis given is blunt abdominal trauma. In looking to the ICD-9-CM index under trauma, there is no listing for abdominal trauma, and it directs you to “Injury of the Specified Site.” By examining the index in this section, we do have two options: an internal organ abdominal injury code (868.00) as well as a “not otherwise specified” abdominal injury code (959.12). In this instance, there does not appear to be a specific internal organ injury. We do know there was a blunt abdominal trauma, so we can code for that injury. The most appropriate code in this instance would be 959.12 Other injury of abdomen. We have also added the external status code for the motor vehicle accident, but unfortunately do not have a great deal of additional detail on that accident. There is no information on where it occurred, whether or not it was work related, or what type of activity the patient was partaking in when hit by the vehicle. We are forced to use unspecified codes in those areas. External status codes are not required by all payers. Verify with your payer to be sure they are needed prior to claims submission.

CPT Answer:
49084 Peritoneal lavage, including imaging guidance, when performed

In this case, our patient presented to the emergency room with some general symptoms after an accident. Based on the documentation provided, the physician in this instance only performed a single procedure, the peritoneal lavage. This code, 49084, is a new code in 2012, replacing 49080 and 49081. In the past, the imaging was coded separately using 46942. In 2012, the imaging services are included in the code for the procedure itself, and will not be coded separately. Cursory exam to determine the need for the procedure is included in all surgical procedures. As there was no documentation of a more extensive evaluation and management service only the surgical procedure is reported.

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