Laparoscopic Port Placement / Diagnostic Laparoscopy
49320
-
49321— With biopsy -
49323— With drainage of lymphocele
[Staging laparoscopy for gastrointestinal/pancreatic/ovarian malignancy / acute abdominal pain / second-look laparoscopy]
[Findings — no evidence of metastatic disease / peritoneal carcinomatosis identified / acute appendicitis / normal abdominal exam]
Diagnostic laparoscopy [with biopsy / with washings]
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] with [known/suspected] [malignancy / acute abdominal pain] presenting for diagnostic laparoscopy to [evaluate for metastatic disease / assess the source of abdominal pain / perform second-look evaluation]. The risks, benefits, and alternatives were discussed with the patient, and informed consent was obtained.
The peritoneal surfaces were [smooth/without nodules/without metastatic deposits / with peritoneal implants in the ___]. The liver surface was [normal/with surface nodules measuring ___]. The omentum was [normal/with omental cake ___]. The [stomach/small bowel/colon/pelvis] appeared [normal/with ___]. [Peritoneal washings were/were not obtained.] [Biopsies were/were not taken from ___]. [Additional findings or none].
The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced. A surgical timeout was performed confirming patient identity, procedure, allergies, and administration of prophylactic antibiotics.
The abdomen was prepped and draped in sterile fashion. Pneumoperitoneum was established to 15 mmHg via [Veress needle / optical trocar / Hasson open technique]. A 12-mm umbilical trocar was placed under direct visualization. One to two additional 5-mm trocars were placed as needed for instrumentation.
A systematic evaluation of the peritoneal cavity was performed:
- Peritoneal surfaces (bilateral diaphragms, paracolic gutters, pelvic peritoneum): [normal/findings]
- Liver (surface and inferior edge): [normal/findings]
- Gallbladder and biliary structures: [normal/findings]
- Stomach and duodenum: [normal/findings]
- Small bowel: [normal/findings]
- Colon: [normal/findings]
- Pelvis (uterus/ovaries, bladder, rectum): [normal/findings]
- Greater omentum: [normal/findings]
- Retroperitoneum: [normal/findings as accessible]
[Peritoneal washings were obtained by instilling 200 mL of warm saline and aspirating for cytology.] [Biopsies were taken from [specific sites] with a biopsy forceps and sent to pathology.] [Based on findings, the planned procedure was [aborted/modified/completed as planned].]
The trocars were removed under visualization. Hemostasis confirmed. Fascial defects were closed with [0-Vicryl]. Skin was closed with [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.
None
[Peritoneal biopsy / peritoneal washings for cytology / omental biopsy] sent to pathology
Minimal (less than 10 mL)
None
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: ***
PROCEDURE PERFORMED: Diagnostic laparoscopy ***
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** presenting for diagnostic laparoscopy for ***. Informed consent obtained.
FINDINGS: Peritoneum ***. Liver ***. Omentum ***. Remaining structures ***. *** washings obtained. *** biopsies taken.
DESCRIPTION OF PROCEDURE:
Supine. General anesthesia. Surgical timeout per protocol.
12-mm umbilical trocar. *** additional trocars. Systematic abdominal inspection performed: peritoneum ***, liver ***, stomach/duodenum ***, small bowel ***, colon ***, pelvis ***, omentum ***. Washings obtained ***. Biopsies taken ***.
Trocars removed. Fascia closed. Skin with 4-0 Monocryl.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: ***
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Staging Laparoscopy for Pancreatic Cancer
Staging laparoscopy was performed prior to planned pancreaticoduodenectomy. The peritoneal surfaces, liver, and omentum were systematically inspected. [No peritoneal or hepatic metastases were identified — the procedure was proceeded with.] [Peritoneal implants / hepatic surface nodules were identified. Biopsies were taken and sent for frozen section — result: [positive for adenocarcinoma / negative for malignancy]. Planned resection was [aborted/continued].] Peritoneal washings were obtained and sent for cytology.
Diagnostic Laparoscopy for Pelvic/Abdominal Pain
The pelvis was carefully inspected. [No acute pathology / appendicitis / ovarian torsion / ectopic pregnancy / endometriosis / adhesions] was identified. [Gynecology was consulted intraoperatively.] [Findings were managed as described in operative note / no intervention was required.] The appendix was inspected and appeared [normal/inflamed — appendectomy was performed].
Charting Tips
- A systematic organ-by-organ documentation of findings is required for diagnostic laparoscopy — vague 'no acute findings' is insufficient. Each anatomic region should be listed and its status documented.
- For staging laparoscopy, document the key negative findings explicitly — 'no peritoneal implants,' 'no liver surface deposits,' 'omentum uninvolved.' These findings are the basis for proceeding with planned resection and must be in the record.
- Peritoneal washings for cytology: document the volume instilled, the location of fluid collection, and that the specimen was labeled and sent for cytology. Positive peritoneal cytology upstages gastric and pancreatic cancer and is not captured if washings are not documented.
Billing Tips
- Laparoscopic port placement for a bariatric or adjustable gastric band system uses 43770 (initial placement, 7.45 wRVU) or 43771-43774 for revisions and removals. These are distinct from access port codes used in other contexts.
- Access port placement performed as part of a primary bariatric procedure (sleeve, bypass) is bundled — do not separately bill port placement in addition to the primary bariatric CPT.
- For totally implantable venous access port (Port-a-Cath), use 36560 (with subcutaneous port, age ≥5, 5.89 wRVU, 10-day global) — this is a vascular access code, not a laparoscopic code. Site: arm, chest, or abdominal wall.
- Document port type, model, size, insertion site, approach, and confirmation of position. For vascular access ports, document fluoroscopic or ultrasound confirmation of tip position at the cavoatrial junction.
- Port removal (without replacement) uses 36590 (0-day global). Port revision uses 36576. Do not use the same code for placement and revision — these are distinct procedures.