by Dee Mandley, RHIT, CCS, CCS-P, CDIP
This coming year five new CPT codes in the range of 49186 - 49190 were created for the reporting of open excision or destruction of intra-abdominal tumors or cysts. The previous codes used to report open excision and destruction of intra-abdominal tumors 49203-49205 have been deleted to make room for these new more detailed codes.
As you can see these codes support removal of tumor(s) or cyst(s) located in three different spaces and are characterized by size. Let’s explore these spaces in more detail. The peritoneal space is located between the parietal peritoneum (the lining of the abdominal wall) and the visceral peritoneum (the lining that covers the abdominal organs) extending from the diaphragm to the pelvic brim.
The mesenteric space: refers to the area occupied by the mesentery, which is a fold of tissue that attaches the intestines to the posterior abdominal wall. This space extends from the duodenum to the colon, enveloping the small intestine and parts of the large intestine.
The retroperitoneal space: refers to the space behind the peritoneal lining where the kidneys, ureters, adrenal glands, aorta and inferior vena cava, and pancreas are located.
A few methods of removal mentioned in the instructional notes are cytoreduction, a method for reducing the bulk of a tumor with the primary goal of removing as much of the tumor as possible and ultrasound desiccation, a method of destruction utilizing ultrasonic waves to produce mechanical vibrations leading to localized heating and cavitation ultimately destroying tissue through thermal and mechanical effects.
Now that we’ve investigated the different spaces where tumors and cysts can be located and a few methods used to excise or destroy tumors or cysts let’s look at the rules associated with these codes.
Measurements associated with these codes is conducted by measuring each tumor or cyst to its maximum length. The measurement is not to include margins or any tissue the tumors or cysts are imbedded in and must be done while the tumor or cyst is insitu before removal or destruction and be documented in the operative report. If only a portion is removed or destroyed then report the measurements for that portion only.
Do not report these codes when the tumor or cyst arises directly from an organ or soft tissue that is separately reportable. In other words, if the tumor or cyst is part of a larger excision it would be integral to the larger procedure.
Consider the example of a patient with tumor implants attached to the ascending colon and a tumor implant measuring 6 cm attached to the mesentery of the descending colon. A partial ascending colon resection is performed along with removal of the tumor implants. A separate excision is performed removing the tumor implants in the mesentery of the descending colon. Two procedure codes would be assigned for this scenario.
44140 Colectomy, partial with anastomosis
49187 Excision or destruction, open, intra-abdominal (i.e. Peritoneal, mesenteric, retroperitoneal), primary or secondary tumor(s) or cyst(s), sum of the maximum length of tumor(s) or cyst(s); 5.1 to 10 cm
The tumor implants associated with the ascending colon resection would not be reported.
Finally, these new codes include open resection of recurrent ovarian, endometrial, tubal or primary peritoneal gynecological malignancies WITHOUT lymphadenectomy. All other open resection of initial or recurrent ovarian, endometrial, tubal or primary peritoneal gynecologic malignancies should be reported within the code range 58943-58960 and for open excision or destruction of endometriomas report code 58999 Unlisted procedure, female genital system.
In conclusion you can see that documentation will play a major role in the assignment of these codes, especially when the instructional notes state the measurements must be taken before removal and documented in the operative note. No using that pathology report as a back-up! It is my hope that you found this information useful. Thank you for taking the time.
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