Summary & Overview
CPT 49188: Open Excision/Destruction of Abdominal Tumors or Cysts (10.1–20 cm)
CPT code 49188 represents an open surgical procedure to excise or destroy one or more tumors or cysts in the abdomen where the total summed maximum lesion length ranges from 10.1 to 20 cm. This procedural code is used to document and bill for open abdominal tumor or cyst removal when lesion burden exceeds smaller-size codes and falls within the specified measurement band. Nationally, accurate coding for sizable intra-abdominal lesions affects clinical documentation, facility resource planning, and payer adjudication for operative services.
Key payers commonly involved with this code include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context for the procedure, typical sites of service, and common modifiers associated with operative coding for complex surgeries. The publication outlines benchmarks and payer coverage considerations where available, highlights documentation elements that commonly drive coding and payment decisions, and summarizes relevant clinical parameters tied to the code descriptor. Data not available in the input is noted where applicable. This summary is intended for hospital coding professionals, surgical practices, billing teams, and policy analysts seeking a national-level reference on CPT code 49188 and its clinical billing context.
Billing Code Overview
CPT code 49188 describes an open surgical procedure to excise or destroy one or more abdominal tumors or cysts when the sum of the maximum lengths of the lesions is 10.1 to 20 cm. The code denotes an open approach rather than a minimally invasive or percutaneous technique.
Service type: Open surgical excision or destruction of abdominal tumors or cysts
Typical site of service: Inpatient or outpatient hospital operating room or ambulatory surgery center, depending on patient condition and facility capabilities.
Clinical & Coding Specifications
Clinical Context
A 52-year-old female presents with progressive abdominal distension and intermittent dull right lower quadrant pain. Cross-sectional imaging (CT abdomen/pelvis) identifies multiple intra-abdominal cystic and solid lesions with a combined maximum linear length measured at 14 cm. The surgical team schedules an open abdominal procedure to excise the tumors/cysts due to size, location, and concern for malignancy. Preoperative workup includes history and physical, labs (CBC, CMP, coagulation studies), informed consent, anesthesia evaluation, and intraoperative pathology (frozen section) as indicated. Intraoperatively, an open midline laparotomy is performed, lesions are identified and resected en bloc with appropriate margin when possible, hemostasis achieved, and abdominal wall closed. Postoperative care includes pain control, wound monitoring, early ambulation, serial abdominal exams, and pathology review to guide further oncologic management. Typical sites of service include an inpatient hospital operating room or ambulatory surgical center for complex open abdominal tumor excisions. The service type is operative open abdominal tumor/cyst excision corresponding to 49188.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when the work, time, or technical difficulty substantially exceeds the usual for 49188. |