2025 CPT code 49321
Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Feed
Laparoscopy, surgical; with biopsy (single or multiple).
This code can be modified with modifiers such as -22 (Increased Procedural Services), -51 (Multiple Procedures), -59 (Distinct Procedural Service), and others, as appropriate, to accurately reflect the services provided.
Medical necessity for this procedure must be established by documenting the patient's symptoms, prior diagnostic testing, and the clinical rationale for performing a laparoscopy with biopsy.The documentation should clearly demonstrate the need for a surgical approach to obtain a tissue diagnosis.
The physician is responsible for preparing and anesthetizing the patient, making the incisions, inserting the laparoscope and instruments, performing the biopsy, irrigating the area, checking for bleeding, and closing the incisions.
In simple words: A laparoscopy is a procedure where a small camera is inserted through a tiny cut in the belly to look at the organs inside. During this procedure, the doctor can also take small tissue samples (biopsies) to be checked for problems.
This code describes a surgical laparoscopy that includes a biopsy. The procedure involves examining the inside of the abdomen with a laparoscope to identify the cause of abdominal or pelvic symptoms and taking tissue samples for laboratory analysis.The procedure begins with a small incision at the umbilicus to inflate the abdomen and improve visualization. Additional small incisions are made to insert the camera and surgical instruments. After examining the organs, biopsies of suspicious tissues are taken. The area is then irrigated, checked for bleeding, and the incisions are closed.
Example 1: A patient presents with chronic pelvic pain. Imaging studies are inconclusive. A diagnostic laparoscopy with biopsy is performed to evaluate for endometriosis or other pelvic pathology., A patient with ascites (fluid in the abdomen) undergoes a laparoscopy with biopsy to determine the cause of the ascites, such as cancer or infection., During a laparoscopy for another reason, such as a cholecystectomy, an unexpected lesion is discovered on the liver. A biopsy is taken during the same procedure to evaluate the lesion.
Documentation should include operative notes detailing the procedure, including the location and number of incisions, organs visualized, biopsies taken, and any other procedures performed. The report from the pathologist analyzing the biopsy should also be included.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- Specialties:General surgery, gynecology, surgical oncology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center