How would you code this OP note?

I think I should use CPT® 49321, but not a 100%....just may be over thinking this!

After induction of general endotracheal anesthesia, the patient was prepped and draped in the usual sterile fashion. Preoperative pause was performed confirming administration of antibiotics and utilization of DVT prophylaxis. An admixture of 0.25% bupivacaine with epinephrine was used for all laparoscopic skin incisions. A primary supraumbilical incision was performed and abdomen was entered with a Veress needle. Pneumoperitoneum was established and a 10/12 mm laparoscopic trocar was inserted. Two additional 5 mm trocars were inserted in a subxiphoid and right costal margin position. The patient was appropriately positioned and diagnostic laparoscopy was performed. There was gallbladder thickening and desmoplasia. The gallbladder fundus appeared thickened with desmoplastic extent into the liver. There was nodularity and desmoplastic standing from the gallbladder fundus into the attached omentum as well as into segments 4B and 5 of the liver. There were multiple white plaque like tumor deposits on the parietal peritoneal surface overlying the right hepatic lobe. There were additional white infiltrative tumor deposits throughout the omentum in particular along the right pericolic gutter and pelvis. There was ascites along the right perihepatic space as well as within the pelvis. Right perihepatic ascites was aspirated. Two separate peritoneal tumor deposits were marked for resection with electrocautery. A full-thickness peritoneal excision of the tumor deposits was performed next with electrocautery. Specimen was submitted to Pathology for frozen section evaluation, which demonstrated presence of metastatic adenocarcinoma. Multiple additional peritoneal tumor deposits was resected next with electrocautery and submitted separately for permanent histopathologic evaluation. Given presence of carcinomatosis, primary tumor resection was not indicated. Ascites was aspirated and 10/12 mm trocar was removed under direct visualization. Supraumbilical fascia was closed with 0 Vicryl using the Carter-Thomason suture passer. Pneumoperitoneum was released and the remaining 5 mm trocars were removed. Subcutaneous tissues were irrigated, and skin was closed with 4-0 Vicryl. I was present for the entire operation until skin closure.

re: How would you code this OP note?

I would code it 49322 for the aspiration portion & 49329 for the excision of the lesions/tumors because MD is not documenting tumor/lesion removal as biopsies, even though he sent them for frozen section. You would pick up the bxs with a PCS code, as well as the excision of the lesions and the aspiration.

re: How would you code this OP note?

Sorry, I was interrupted by phone as I was posting answer. Assuming your facility or DR uses PCS codes, the PCS codes would show all of the above. SOME facility providers are using PCS codes for all procedures whether Inpatient or Outpatient patient types. Original poster did not indicate if she is coding for MD or facility and if IP or OPS.

re: How would you code this OP note?

This is for MD's charge.