2025 CPT code 49000
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Exploratory laparotomy or celiotomy, with or without biopsy, as a separate procedure.
Modifiers may be applicable depending on the specific circumstances of the procedure.For example, modifier 51 may be used if multiple procedures are performed during the same surgical session. Consult the most recent CPT codebook and modifier guidelines for applicable modifiers.
Medical necessity for an exploratory laparotomy is established when there is a clinical indication suggesting the need for direct visualization of the abdominal cavity to diagnose or treat a condition. This may include persistent unexplained abdominal pain, suspected trauma, palpable masses, or signs of internal bleeding or infection.
The surgeon is responsible for the pre-operative preparation, the surgical incision, exploration of the abdominal cavity, obtaining tissue samples (biopsy if necessary), wound irrigation, hemostasis (controlling bleeding), removal of instruments, and closure of the incision.Post-operative care may be included or billed separately, depending on the payer's guidelines.
In simple words: The doctor makes a cut in the belly to look inside and check for problems like pain, lumps, injuries, or infections.If they find anything suspicious, they take a small sample to test in a lab.
This CPT code encompasses an exploratory laparotomy or celiotomy performed as a distinct procedure, separate from any other more extensive surgeries.The procedure involves a surgical incision into the abdominal cavity to visually inspect the abdominal organs and structures for evidence of disease, trauma, or infection.A biopsy of suspicious tissue may be taken and sent for pathological examination. The incision site may vary depending on the area of concern, potentially ranging from the xiphoid process to the pubis, or laterally in the upper or lower abdomen.The procedure concludes with wound irrigation, hemostasis (control of bleeding), instrument removal, and closure of the incision.
Example 1: A patient presents with acute abdominal pain of unknown origin. An exploratory laparotomy is performed to identify the source of the pain. No specific pathology is found. , A patient sustains blunt abdominal trauma in a motor vehicle accident. An exploratory laparotomy is performed to assess for internal injuries.A splenic laceration is identified and repaired., A patient experiences persistent abdominal pain and a palpable mass.An exploratory laparotomy is performed. A tumor is discovered and biopsied.
* Thorough preoperative history and physical examination detailing the reason for the procedure.* Operative report detailing the incision site, organs visualized, findings during exploration, any biopsies performed (specimen description and location), and the closure technique.* Pathology report if a biopsy was performed.* Anesthesia record.* Postoperative progress notes.
** The provided text states that this code is only reported when it's not integral to a more extensive procedure.Always ensure proper documentation supports the medical necessity of this code.This code may be bundled with other services based on payer-specific guidelines.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- RVU: This information is not available in the provided text.Refer to the current year's CPT codebook or a relevant fee schedule for RVU values.
- Global Days: This information is not available in the provided text. The global period will vary based on payer and other factors.
- Payment Status: Active
- Modifier TC rule: This code does not have a Technical Component (TC) modifier.It represents the entire procedure.
- Fee Schedule: Historical fee schedule information is not available in the provided data.Consult historical CPT codebooks or fee schedules for this information.
- Specialties:General Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center