ICD-10cm

Hemorrhoids

Pay external vs internal and if they are documented as bleeding

Ileostomy

Use Attention to ileostomy diagnosis code for closure of ileostomy unless there is a complication

 

 

CPT

 Digestive System (40490-49999)

The digestive system subsection is divided by anatomical site and procedure. Similar to the anatomy of the digestive system this section starts with the lips and ends with the anus.This subsection includes codes for accessory organs such as the liver, gallbladder, and pancreas.

 

Below you will find the organization of most of the subsections and the procedures found within the subsections

 

Incision

Includes:

Incision and drainage (I&D)

I&D abscesses and removal of foreign

Biopsies

Suturing

Placement of seton

Removal of calculus

You will have to know the approach.

 

Manipulation:

Includes:

Dilation

Reduction

Removal of foreign matter

Note: Surgeon may use a balloon, a dilator, and/ or a guide wire.

 

Introduction

Includes:

Placements

Injections

Revisions

Reinsertions

Ligation and removals are sometimes included in procedures.

 

Enterostomy

Also referred to as external fistulization of intestines, this code is used for the formation of stomas. The most commonly known stoma is a colostomy.

 

Note:

Closure Ileostomy

Look up closure/Enterostomy(make a note under the ileostomy term in your CPT index to use 44620- 44626)

 

 

Endoscopy

Code will depend on the anatomic site that is being examined.

Code it to the farthest extent of the procedure.

Note:The most common reasons for performing endoscopies is screening for diseases, such as cancer. Code the screening code regardless of the outcome of surgery as your principle if that is purpose of procedure. You will need to look up "screening" in the index of disease in your ICD- 9cm book. And confirm your choice in the tabular section.

 

Laparoscopy

Includes:

Minimally invasive procedure are performed via laparoscope.

Usually performed in the abdominal and pelvic cavities.

Many major operations, such as cholecystectomy, appendectomy, anastomosis, removals and hernia repair,are performed via laparoscope.

 

Excision/Destruction

Includes:

Some biopsies.

Removal of foreign matter

You may need to include the type of repair or closure.

You'll need to know the method of destruction (chemical vs laser)

You'll need to know if a tumor is benign or malignant before coding the procedure.

 

Repairs

Includes:

Partial or complete repairs

Physicians might complete them in stages

Codes are based on the approach used, level of complexity, size, type of revision, ligation, suturing, and/or stapling.

 

Other Procedures

Includes

Fixations

SuTures

Revisions

Grafting,

Unlisted procedure

Closure

Dilation

Ligation

Transfers

Construction

Exclusions

Ablations

Lavage .

 

Anastomosis Surgeons reconnect the patient's intestines after a resection. Doctors perform this procedure one of three ways:

1. End to end

2. End to side

3. Side to side

 

 

Anatomical sites 

The digestive system section starts wit the lips. If a procedure is performed on the skin of the lips do not use codes from this section

 

Lips 40490- 40799

 

Excision 

Code 40500 Vermilionectomy is excision of the lipstick region of the upper and lower lip and includes a repair with mucosal advancement

 

Repair (Cheiloplasty 40650- 40761)

 

This subsection is used to code for plastic surgery of the lips.

When coding for this section make sure you pay attent to codes for repair of cleft lip.

Code 40700 Plastic repair of cleft lip nasal deformity: Primary,complete, unilateral

Code 40701 primary bilateral 1- stage proceure

Code 40702 primary bilateral 1 of 2 stages

Code 40720 secondary by recreation of defect and reclosure

Read over all of the parenthetical notes in this section

Code 40761 with cross lip pedicle flap (abbe- estalander type), including sectioning and inserting of pedicle

 

Key notes Do not report codes from the integumentary section with 40510- 40527. Repairs are included

 

Vestibule of mouth(40800-40899)

Read about the anatomical location under the subheading for this section in your CPT book

 

Excision Destruction

Code 40819 is coded for excison of frenulum.

 

Repair

Code 40840- 40845) for vestibuloplasty . The physicion must document whether the procedure was peformed unilater or bilateral and if it is arterior or posterier, etc.

 

Tongue and floor 41000- 41599

Incision

Codes in this subsection includes incision and drainage of abscess Abscesses, cysts, or hematomas in this area are coded by location.

Codes 41000-41019 are intraoral

Codes 41015-41018 are extraoral

 

Excision

Codes 41100-41155 used for oral biopsies, excision of oral lesions, and tongue removal.

 

Dentoalveolar Structures 41800-41899

This section includes the gums (or soft tissue structures) and bone that anchor the teeth. Conditions reported here include I&D of abscesses, cysts, hematoma, or excision of a lesion with a simple repair. Some of the codes are based on the quadrant in which the procedure is performed.

 

 

Palate and Uvula(42000- 42299)

These codes are use tor report procedures on the roof of the mouth and the uvula.

 

Excision, Destruction

If skin grafting is necessary to repair the defect of the excision, the grafting procedure is reported in addition to the excision. The graft code is chosen based on if the graft was a skin graft or a mucosal graft. Uvulectomy (syn – staphylectomy) is removal of the uvula (42140). Also listed here is a palatopharyngoplasty (42145).

 

 

Uvulopalatopharyngoplasty or palatophayngoplasty 42145

Use a modifier 22 and submit a cover letter if significant additional time and effort is documented in the operative report.

For removal of torus mandibularis or maxillary torus palatinus in addition to a palatopharyngoplasty, see CPT® codes 21031 or 21032. 

 

Repair

Palate

If a bone graft is used, code the bone graft separate

 

Salivary glands (42300-42699)

Codes include procedures such as Incision, Excision, Repair, and Other Procedures. Codes in this section specific to the gland.

Code 42300 is coded for incision for drainage of a parotid abscess

Code 42310 is coded for incision and drainage of a submaxillary or sublingual abscess.

 

 

Pharynx, Adenoids and Tonsils (42700- 42999)

 

Excision

Tonsillectomy is sometimes performed with a adenoidectomy (search documentation to verify if a adenoidectomy was performed with the tonsillectomy)

When coding for

tonsillectomies and adenoidectomies pay attention to the age of the patient.

Codes are considered bilateral and are reported only once without modifier 50

 

Radical resection of tonsils (42842) has a extremely extensive post op wound site and is packed open and grafted at a later session

Radical resection of tonsils code 42845 a rotation flap is used and if the mandible is resected a bone graft from the fibula is used to reconstruct the jaw

 

A limited pharygectomy is coded 42890.

For the removal of a small part of the pharyngeal wall or pyriform sinus code limited pharyngectomy (42890).

 

 

Esophagus 43020- 43499

Code 43020 cervical approach and 43045 thoracic approach is coded for removal of a foreign body

An ERCP is abbreviatedd for endoscopic retrograde cholangiopancreatography (43260)

 

Manipulation (43450-43460)

These codes are for dilation of the esophagus by various methods.

Code seperately for radiological supervision and interpretation if performed wih procedure.

 

 

Endoscopies

If a laparoscopy is converted to an open procedure code the open procedure only

If there is more than one polyp removed using different techniques code for each one example hot biopsy and snare technique with a modifier 59 to show that they were removed from different sites

Use code 43220 for endoscopic ballon dilation of esophagus. When not performed with scope use an appropriate code from the series 43450–43453 under the Manipulation

 

EGD

If the documentation does not state the physician examined the proximal duodenum or jejunum use a modifier 52

According to CPT® instructions if a complete examination of an egd was not performed, you may report the examination using the egd code range and append a 52 modifier to report that the full examination was not completed

 

All of these terms means the same:

ESOPHAGOGASTRODUDENOSCOPY

EGD

UPPER GASTROINTESTINAL SCOPE

UPPER GI SCOPE

 

 

PEG

Code 43246 is used for percutaneous endoscopic gastrostomyre is no

code for removal because it is included in E/M SERVICES. Code 43760 when tube is changed without an egd

 

Gastrostomy button is coded just like any other peg,

If two surgeons are required during a PEG use modifier 62

 

Code 43227 or 43255 is not usually reported when the bleeding is not due to endoscopy unless the patient returns to the operating room later that day or a different day to control bleeding

 

 

STOMACH 43500- 43999

This subheading includes codes for incision and removal of a foreign body, excision of a stomach tumor.

 

Excision

 

When a gastrectomy is performed some or all of the the stomach is removed.

When coding for gastrectmies you will need to make sure that you read the description carefully because the codes in this section is divided by whether the gastrectomy was partial or total. The codes also include description of other procedurse being performed with the gastrectomies.

 

Code 43620 is gastrectomy total with esophagoenterostomy.

Code 43621 Gastrectomy total with Roux- en Y reconstruction

Code 43622 is gastrectomy total with formation of intestional pouch, any type

Code 43631 is gastrectomy partial distal with gastrodudenostomy

Code 43632 is gastrectomy partial distal with gastrojejunostomy

Code 43634 is gastrectomy partial with formation of intestinal pouch

 

Introduction

This section includes codes for the placement, changing, and repositioning of feeding tubes.

Code (43752) is only coded when the physician performs the procedure under fluoroscopic guidance, when performed with a procedure do not report separately

Code 43753 used when physician pumps stomach for poisoning, overdose, or gastrointestinal hemorrhage

Codes 43754 and 43755 are reported when contents of the stomach are aspirated for diagnostic purposes

 

 

Bariatric Surgery (43770- 437755)

Bariatric surgery is performed using minimally invasive techniques (laparoscopic surgery) it changes the digestive system anatomy by making the stomach smaller and sometimes changes the small intestine to limit the amount of food that can be eaten and digested.

 

 

Other procedures (43800-43999)

Contains a variety of open surgical procedures on the stomach

Codes 43846- 43847 is coded for gastric bypass for morbid obesity

Code 43886 is coded for an open gastric restrictive procedure with revision of subcutaneous port component only.

Code 43887 is coded for Gastric restrictive procedure, open with removal of subcutaneous port component only

Code 43887 is coded for a gastric restrictive procedure with removal and replacement of the port is reported with 43888.

 

I

Excision

If a Roux-en y gastrectomy (43633) is performed laparoscopically code an unlisted code 43659

Nasogastric/orogastric intubation

(43752) is only coded when the physician performs the procedure under fluoroscopic guidance, when performed with a procedure do not report separately

Code 43753 used when physician pumps stomach for poisoning, overdose, or gastrointestinal hemorrhage

Codes 43754 and 43755 are reported when contents of the stomach are aspirated for diagnostic purposes

Incarcerated hernia is constricted by the defect and cannot be reduced by simple manipulation.

A strangulated hernia is considered a medical emergency.

The use of mesh or prosthesis may only be reported as an add on code for incisional or ventral hernia repairs (code 49568).

Bilateral hernia repairs are reported with CPT® modifier 50.

Intestine

Endoscopy

 

COLONOSCOPY

MAKE SURE THE SCOPE GOES INTO THE COLON TO CODE FOR COLONOSCOPY

ENDOSCOPY FROM THE RECTUM to ILEUM= COLONOSCOPY

 

Note

Intraoperative endoscopies (eg.  Intraoperative sigmoidoscopy)are included to major GI procedures(do not code separately)

 

Colonoscopy w/ Polypectomy by cold biopsy use code 45380

 

Don't use modifier rt and lt when coding hemicolectomies.

 

APPENDIX

Excision

It is important to know if an appendectomy (44955)is considered incidental to other procedures unless it is performed for a diagnosis.

 

Anus

Excision

When multiple hemorrhoids are removed using different methods code for each method

 

Abdomen

Repairs

Hernia repairs

Mesh? When coding for incisional and ventral hernias (49560- 49566) you will need to use code 49568 if mesh was used.