2025 CPT code 49010
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Feed
Exploration, retroperitoneal area with or without biopsy(s) (separate procedure)
Modifiers applicable: 22, 51, 52, 53, 54, 55, 56, 58, 59, 62, 76, 77, 78, 79, 80, 81, 82, 99, AQ, AR, AS, CR, ET, GA, GC, GJ, GR, KX, Q5, Q6, QJ, XE, XP, XS, XU.
Medical necessity must be established by documenting the clinical signs, symptoms, or other objective findings that justify the need for the surgical exploration. The reason for the exploration (e.g. abdominal pain, mass, suspected injury) should be clearly linked to the patient's condition and the potential benefits of the procedure.If a biopsy is performed, the reason for suspicion and the area biopsied should be documented.
The surgeon is responsible for the entire surgical process, from preoperative planning to postoperative care. This includes patient evaluation, obtaining informed consent, performing the surgery, managing any complications, and providing post-operative instructions.
In simple words: The doctor examines the organs behind the lining of your abdomen to find the cause of problems like pain, lumps, injuries, or infections. They might take a tissue sample for testing. This is done through an incision in your belly.
This procedure involves examining the organs behind the peritoneum (the membrane lining the abdominal cavity) to identify causes of abdominal pain, masses, suspected injuries, or infections.A sample of suspicious tissue may be taken for lab analysis.The surgeon makes an incision, examines the organs, may perform a biopsy or drain fluid, and then closes the incision.This code is for diagnostic exploration only and is not used if therapeutic treatment is performed during the same session. (To report wound exploration due to penetrating trauma without laparotomy, use 20102).
Example 1: A patient presents with persistent right lower quadrant pain.An exploratory retroperitoneal surgery (49010) is performed to rule out appendicitis or other causes., Following blunt abdominal trauma, a patient undergoes exploratory retroperitoneal surgery (49010) to assess for retroperitoneal hematoma or organ damage., A patient with a suspected retroperitoneal mass undergoes exploratory surgery (49010) with biopsy of the mass for diagnostic purposes.
Documentation should include operative report detailing the exploration, including findings, biopsies taken (if any), and any fluid drainage. Preoperative and postoperative diagnoses, indications for surgery, and medical necessity should be clearly documented.
- Revenue Code: P1G - MAJOR PROCEDURE - OTHER
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:General Surgery, Trauma Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center