04-4-2026 Surgical Diagnostic and Staging Procedure-Don’t Forget About Codes 03-09
Scenario:
- 87-year-old female who presented w/lethargy and weight loss.
- CT scan showed a likely pre-obstructing cancer in the rectosigmoid junction+ liver mets
- Elected to proceed with exploratory laparoscopy with loop colostomy formation and liver biopsy
- 4-4-2026 Laparoscopic loop colostomy formation. Laparoscopic Tru-Cut needle biopsy of the liver- Path: metastatic adenocarcinoma from colon
Question: How would you code the 4-4-2026 Surgical Diagnostic and Staging Procedure?
- 00 No surgical diagnostic or staging procedure was performed.
- 01 A biopsy (incisional, needle, or aspiration) was done to a site other than the primary site.
No exploratory procedure was done. - 02 A biopsy (incisional, needle, or aspiration) was done to the primary site; or biopsy or removal of a lymph node to diagnose or stage lymphoma.
- 03 A surgical exploration only. The patient was not biopsied or treated.
- 04 A surgical procedure with a bypass was performed, but no biopsy was done.
- 05 An exploratory procedure was performed, and a biopsy of either the primary site or another site was done.
- 06 A bypass procedure was performed, and a biopsy of either the primary site or another site was done.
- 07 A procedure was done, but the type of procedure is unknown.
- 09 No information of whether a diagnostic or staging procedure was performed.
Answer: 06 A bypass procedure was performed, and a biopsy of either the primary site or another site was done.
