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2025 CPT code 49084

Peritoneal lavage with imaging guidance to detect internal bleeding.

Follow current CPT guidelines for surgical procedures and coding conventions.Appropriate modifiers may be applied based on circumstances (e.g., 59 for distinct procedural service).

Modifiers may apply depending on the circumstances of the procedure.Refer to the CPT codebook for a complete list of applicable modifiers.

Peritoneal lavage is medically necessary when there is a high clinical suspicion of intra-abdominal bleeding in hemodynamically unstable patients or when non-invasive methods are inconclusive.It is a rapid method for assessing the need for immediate surgery.

The physician is responsible for prepping the patient, administering anesthesia (if applicable), making the incision, inserting the tube and catheter, performing the lavage, checking for bleeding, removing instruments, and closing the incision.The physician may utilize imaging guidance during the procedure.

IMPORTANT:Do not report 49084 with 76942, 77002, 77012, 77021. For percutaneous image-guided drainage of retroperitoneal abscess by catheter, use 49406.

In simple words: This procedure involves washing out the abdominal cavity with fluid to look for internal bleeding. A small incision is made near the belly button to insert a tube. The doctor uses fluid to clean the area and checks for blood.Imaging may be used to help see inside.

Peritoneal lavage is a procedure where the peritoneal cavity is washed out to detect the presence of internal bleeding.The procedure involves inserting a long, flexible plastic tube into the abdomen through a small incision near the umbilicus. A catheter is then inserted towards the pelvis. Saline or warm water is instilled into the peritoneal cavity and then suctioned out. Imaging guidance may be used to visualize internal structures.After checking for bleeding, instruments are removed, and the incision is closed.

Example 1: A patient presents to the emergency department after a motor vehicle accident with abdominal pain and hemodynamic instability. Peritoneal lavage is performed to rapidly assess for intra-abdominal bleeding., A patient undergoes a laparoscopic cholecystectomy (gallbladder removal). During the surgery, a small bowel injury occurs. Peritoneal lavage is used to identify and quantify any bleeding after repair., A patient with a history of blunt trauma to the abdomen is found to have free fluid in the abdomen on ultrasound. Peritoneal lavage is utilized to determine the nature of the fluid.

Complete medical history, physical examination findings, operative report detailing the procedure (including fluid instilled and retrieved, any evidence of blood), imaging reports (if applicable), and pathology report (if any tissue samples were collected). Documentation must support medical necessity.

** This information is not available in the provided source. Always refer to the latest CPT codebook and payer guidelines for accurate billing.

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