2021 BILLING AND CODING GUIDE GENERAL SURGERY
2021 BILLING AND CODING GUIDE GENERAL SURGERY
2021 Medicare Physician, Hospital Outpatient, ASC Coding and Payment
Rates listed in this guide are based on their respective site of care- physician office, ambulatory surgical center, or hospital outpatient department. All rates provided are for the Medicare National Average rounded to the nearest whole number for 2021 and do not represent adjustment specific to the provider's location or facility. Commercial rates are based on individual contracts. Providers are encouraged to review contracts to verify their specific contracted allowables. Medtronic products associated with general surgery procedures addressed within this guide do not have a dedicated HCPCS1 level II coding assignment. Providers may choose to report A4649 Surgical supply; miscellaneous for purposes of cost tracking. Medicare considers the use of surgical supplies to be included in the payment for the associated CPT, and no additional payment is allowed.
CPT? CODE2
CODE DESCRIPTION
PHYSICIAN3
AMBULATORY
HOSPITAL
SURGICAL CENTER4 OUTPATIENT4
60540 60545
60650
44950 44955
44960 44970 47562 47563 47564 47600
ADRENALECTOMY Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure)
Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); with excision of adjacent retroperitoneal tumor Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal
APPENDECTOMY Appendectomy
Appendectomy; when done for indicated purpose at time of other major procedure (not asseparate procedure) (List separately in addition to code for primary procedure) Appendectomy; for ruptured appendix with abscess or generalized peritonitis
Laparoscopy, surgical, appendectomy
CHOLECYSTECTOMY Laparoscopy, surgical; cholecystectomy
Laparoscopy, surgical; cholecystectomy with cholangiography
Laparoscopy, surgical; cholecystectomy with exploration of common duct
Facility Only: $1,104 Inpatient only, not reimbursed for hospital outpatient or ASC
Facility Only: $1,276 Inpatient only, not reimbursed for hospital outpatient or ASC
Facility Only:$1,222 Inpatient only, not reimbursed for hospital outpatient or ASC
Facility Only: $664 $1,406 Facility Only: $85 N/A for ASC
$3,183
Not separately payable, packaged into payment for other procedures
Facility Only: $905 Facility Only: $622
Inpatient only, not reimbursed for hospital outpatient or ASC
$2,306
$5,060
Facility Only: $682 $2,306 Facility Only: $742 $2,306
$5,060 $5,060
Facility Only: $1,155 $2,306
$5,060
Cholecystectomy
Facility Only: $1,104 Inpatient only, not reimbursed for hospital outpatient or ASC
1
CPT? CODE2
CODE DESCRIPTION
PHYSICIAN3
AMBULATORY
HOSPITAL
SURGICAL CENTER4 OUTPATIENT4
47605 47610 47612 47620 43107 43108 43112 43113 43116 43117
43118
43121 43122 43123
43124
Cholecystectomy; with cholangiography
Facility Only: $1,164 Inpatient only, not reimbursed for hospital outpatient or ASC
Cholecystectomy with exploration of common duct
Facility Only: $1,295 Inpatient only, not reimbursed for hospital outpatient or ASC
Cholecystectomy with exploration of common duct; with choledochoenterostomy
Facility Only: $1,319 Inpatient only, not reimbursed for hospital outpatient or ASC
Cholecystectomy with exploration of common duct; with transduodenal sphincterotomy or sphincteroplasty, with or without cholangiography ESOPHAGECTOMY Total or near total esophagectomy, without thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty (transhiatal)
Facility Only:$1,424 Inpatient only, not reimbursed for hospital outpatient or ASC
Facility Only:$3,044 Inpatient only, not reimbursed for hospital outpatient or ASC
Total or near total esophagectomy, without thoracotomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation and anastomosis(es)
Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty
Facility Only: $4,541 Facility Only: $3,558
Inpatient only, not reimbursed for hospital outpatient or ASC
Inpatient only, not reimbursed for hospital outpatient or ASC
Total or near total esophagectomy, with thoracotomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es)
Facility Only: $4,435 Inpatient only, not reimbursed for hospital outpatient or ASC
Partial esophagectomy, cervical, with free intestinal graft, including microvascular anastomosis, obtaining the graft and intestinal reconstruction
Facility Only: $5,077 Inpatient only, not reimbursed for hospital outpatient or ASC
Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with thoracic esophagogastrostomy, with or without pyloroplasty (Ivor Lewis)
Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es)
Facility Only: $3,326 Inpatient only, not reimbursed for hospital outpatient or ASC
Facility Only: $3,703 Inpatient only, not reimbursed for hospital outpatient or ASC
Partial esophagectomy, distal two-thirds, with
Facility Only: $2,918 Inpatient only, not reimbursed for hospital
thoracotomy only, with or without proximal
outpatient or ASC
gastrectomy, with thoracic esophagogastrostomy,
with or without pyloroplasty
Partial esophagectomy, thoracoabdominal or abdominal Facility Only: $2,609 Inpatient only, not reimbursed for hospital
approach, with or without proximal gastrectomy; with
outpatient or ASC
esophagogastrostomy, with or without pyloroplasty
Partial esophagectomy, thoracoabdominal or abdominal Facility Only: 4,598 Inpatient only, not reimbursed for hospital
approach, with or without proximal gastrectomy; with
outpatient or ASC
colon interposition or small intestine reconstruction,
including intestine mobilization, preparation, and
anastomosis(es)
Total or partial esophagectomy, without reconstruction Facility Only: $3,886 Inpatient only, not reimbursed for hospital
(any approach), with cervical esophagostomy
outpatient or ASC
2
CPT? CODE2
CODE DESCRIPTION
PHYSICIAN3
AMBULATORY
HOSPITAL
SURGICAL CENTER4 OUTPATIENT4
43620 43621 43622 43631 43632 43633 43634 43280 43281 43282 43325 43332
43333
43334 43335
43336
43337
GASTRECTOMY
Gastrectomy, total; with esophagoenterostomy
Facility Only: $2,046 Inpatient only, not reimbursed for hospital outpatient or ASC
Gastrectomy, total; with Roux-en-Y reconstruction
Facility Only: $2,340 Inpatient only, not reimbursed for hospital outpatient or ASC
Gastrectomy, total; with formation of intestinal pouch, any Facility Only: $2,385 Inpatient only, not reimbursed for hospital
type
outpatient or ASC
Gastrectomy, partial, distal; with gastroduodenostomy
Facility Only: $1,496 Inpatient only, not reimbursed for hospital outpatient or ASC
Gastrectomy, partial, distal; with gastrojejunostomy
Facility Only: $2,092 Inpatient only, not reimbursed for hospital outpatient or ASC
Gastrectomy, partial, distal; with Roux-en-Y reconstruction
Facility Only: $1,980 Inpatient only, not reimbursed for hospital outpatient or ASC
Gastrectomy, partial, distal; with formation of intestinal Facility Only: $2,193 Inpatient only, not reimbursed for hospital
pouch
outpatient or ASC
REPAIR OF DIAPHRAGMATIC HERNIA (HIATAL HERNIA)
Laparoscopy, surgical, esophagogastric fundoplasty (eg, Facility Only: $1,113 $3,794 Nissen, Toupet procedures)
$8,908
Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh
Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh
Esophagogastric fundoplasty; with fundic patch (Thal-Nissen procedure)
Facility Only: $1,588 $3,794
$8,908
Facility Only: $1,785 $3,794
$8,908
Facility Only: $1,403 Inpatient only, not reimbursed for hospital outpatient or ASC
Repair, paraesophageal hiatal hernia (including
Facility Only: $1,186 Inpatient only, not reimbursed for hospital
fundoplication), via laparotomy, except neonatal; without
outpatient or ASC
implantation of mesh or other prosthesis
Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis
Facility Only: $1,299 Inpatient only, not reimbursed for hospital outpatient or ASC
Repair, paraesophageal hiatal hernia (including
Facility Only: $1,278 Inpatient only, not reimbursed for hospital
fundoplication), via thoracotomy, except neonatal; without
outpatient or ASC
implantation of mesh or other prosthesis
Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; with implantation of mesh or other prosthesis
Facility Only: $1,366 Inpatient only, not reimbursed for hospital outpatient or ASC
Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; with implantation of mesh or other prosthesis
Facility Only: $1,484 Inpatient only, not reimbursed for hospital outpatient or ASC
Facility: $1,582
Inpatient only, not reimbursed for hospital outpatient or ASC
3
CPT? CODE2
CODE DESCRIPTION
PHYSICIAN3
AMBULATORY
HOSPITAL
SURGICAL CENTER4 OUTPATIENT4
43210
43280 43325 43327 43328
47120 47122 47125 47130
38500 38510 38520 38525 38530 38542 38562 38564 38570 38571 38572
38700 38720 38724 38740
FUNDOPLICATION (EG, FOR GERD) Esophagogastroduodenoscopy, flexible, transoral; with Facility: $439 esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed
Laparoscopy, surgical, esophagogastric fundoplasty (eg, Facility: $1,113 Nissen, Toupet procedures)
Esophagogastric fundoplasty; with fundic patch (ThalNissen procedure) Esophagogastric fundoplasty partial or complete; laparotomy
Facility: $1,403 Facility: $845
Esophagogastric fundoplasty partial or complete; thoracotomy
Facility: $1,150
HEPATECTOMY (LIVER) Hepatectomy, resection of liver; partial lobectomy
Facility: $2,408
Hepatectomy, resection of liver; trisegmentectomy Hepatectomy, resection of liver; total left lobectomy Hepatectomy, resection of liver; total right lobectomy
Facility: $3,523 Facility: $3,167 Facility: $3,405
LYMPH NODE PROCEDURES Biopsy or excision of lymph node(s); open, superficial
Biopsy or excision of lymph node(s); open, deep cervical node(s) Biopsy or excision of lymph node(s); open, deep cervical node(s) with excision scalene fat pad
Biopsy or excision of lymph node(s); open, deep axillary node(s) Biopsy or excision of lymph node(s); open, internal mammary node(s) Dissection, deep jugular node(s) Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic
Facility: $263 Non-Facility: $351 Facility: $428 Non-Facility: $545 Facility: $478 Non-Facility: NA Facility: $453 Non-Facility: NA Facility Only: $580
Facility Only: $529 Facility Only: $724
$3,794
$8,908
$3,794
$8,908
Inpatient only, not reimbursed for hospital outpatient or ASC Inpatient only, not reimbursed for hospital outpatient or ASC
Inpatient only, not reimbursed for hospital outpatient or ASC
Inpatient only, not reimbursed for hospital outpatient or ASC
Inpatient only, not reimbursed for hospital outpatient or ASC Inpatient only, not reimbursed for hospital outpatient or ASC Inpatient only, not reimbursed for hospital outpatient or ASC
$1,176 $1,176 $1,176
$3,158 $3,158 $3,158
$1,176
$1,176 $2,306 N/A for ASC
$3,158
$3,158 $5,060 $8,908
Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or splenic)
Facility Only: $726 Inpatient only, not reimbursed for hospital outpatient or ASC
Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple
Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy
Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple
Suprahyoid lymphadenectomy
Facility Only: $527 $2,306 Facility Only: $676 $3,794 Facility Only: $930 $3,794
Facility Only: $817 $2,251
$5,060 $8,908 $8,908
$5,534
Cervical lymphadenectomy (complete)
Cervical lymphadenectomy (modified radical neck dissection) Axillary lymphadenectomy; superficial
Facility Only: $1,362 $2,788
$8,920
Facility Only: $1,471 Inpatient only, not reimbursed for
hospital outpatient or ASC
Facility Only: $907 $2,306
$5,060
4
CPT? CODE2 38746 38747
38760 38765
38770 38780
19300 19301 19302 19303 19305 19306 19307
48140 48145 48146 48150
CODE DESCRIPTION
PHYSICIAN3
AMBULATORY SURGICAL CENTER4
HOSPITAL OUTPATIENT4
Thoracic lymphadenectomy by thoracotomy,
Facility Only: $219 Inpatient only, not reimbursed for hospital
mediastinal and regional lymphadenectomy (List
outpatient or ASC
separately in addition to code for primary procedure)
Abdominal lymphadenectomy, regional, including celiac, Facility Only: $274 Inpatient only, not reimbursed for hospital
gastric, portal, peripancreatic, with or without para-aortic
outpatient or ASC
and vena caval nodes (List separately in addition to code
for primary procedure)
Inguinofemoral lymphadenectomy, superficial,
Facility Only: $861 $2,251
$5,534
including Cloquets node (separate procedure)
Inguinofemoral lymphadenectomy, superficial, in
Facility Only: $1,338 Inpatient only, not reimbursed for hospital
continuity with pelvic lymphadenectomy, including
outpatient or ASC
external iliac, hypogastric, and obturator nodes
(separate procedure)
Pelvic lymphadenectomy, including external iliac,
Facility Only: $821 Inpatient only, not reimbursed for hospital
hypogastric, and obturator nodes (separate
outpatient or ASC
procedure)
Retroperitoneal transabdominal lymphadenectomy,
Facility Only: $1,061 Inpatient only, not reimbursed for hospital
extensive, including pelvic, aortic, and renal nodes (separate
outpatient or ASC
procedure)
MASTECTOMY Mastectomy for gynecomastia
Facility: $440
$1,176
$3,158
Non-Facility: $599
Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy Mastectomy, simple, complete
Facility Only: $680 $1,176 Facility Only: $935 $2,251
Facility Only:$989 $2,251
$3,158 $5,534
$5,534
Mastectomy, radical, including pectoral muscles, axillary lymph nodes Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation) Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle
Facility Only: $1,181 Inpatient only, not reimbursed for hospital outpatient or ASC
Facility Only: $1,258 Inpatient only, not reimbursed for hospital outpatient or ASC
Facility Only: $1,222 $2,251
$5,534
PANCREATECTOMY
Pancreatectomy, distal subtotal, with or without
Facility Only: $1,612 Inpatient only, not reimbursed for hospital
splenectomy; without pancreaticojejunostomy
outpatient or ASC
Pancreatectomy, distal subtotal, with or without splenectomy; with pancreaticojejunostomy
Facility Only: $1,688
Inpatient only, not reimbursed for hospital outpatient or ASC
Pancreatectomy, distal, near-total with preservation of duodenum (Child-type procedure)
Facility Only: $1,953 Inpatient only, not reimbursed for hospital outpatient or ASC
Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy,
Facility Only: $3,213 Inpatient only, not reimbursed for hospital outpatient or ASC
choledochoenterostomy and gastrojejunostomy (Whipple-
type procedure); with pancreatojejunostomy
5
CPT? CODE2
CODE DESCRIPTION
PHYSICIAN3
AMBULATORY
HOSPITAL
SURGICAL CENTER 4 OUTPATIENT4
48152
48153
48154
48155 38100 38101 38102 38120 S2900
Pancreatectomy, proximal subtotal with total
Facility Only:$2,989 Inpatient only, not reimbursed for hospital
duodenectomy, partial gastrectomy,
outpatient or ASC
choledochoenterostomy and gastrojejunostomy (Whipple-
type procedure); without pancreatojejunostomy
Pancreatectomy, proximal subtotal with near-total
Facility Only: $3,203 Inpatient only, not reimbursed for hospital
duodenectomy, choledochoenterostomy and
outpatient or ASC
duodenojejunostomy (pylorus-sparing, Whipple- type
procedure); with pancreatojejunostomy
Pancreatectomy, proximal subtotal with near-total
Facility Only: $3,002 Inpatient only, not reimbursed for hospital
duodenectomy, choledochoenterostomy and
outpatient or ASC
duodenojejunostomy (pylorus-sparing, Whipple- type
procedure); without pancreatojejunostomy
Pancreatectomy, total
Facility Only: $1,881 Inpatient only, not reimbursed for hospital
outpatient or ASC
SPLENECTOMY
Splenectomy; total (separate procedure)
Facility Only: $1,186 Inpatient only, not reimbursed for hospital
outpatient or ASC
Splenectomy; partial (separate procedure)
Facility Only: $1,202 Inpatient only, not reimbursed for hospital
outpatient or ASC
Splenectomy; total, en bloc for extensive disease, in
Facility Only: $268 Inpatient only, not reimbursed for hospital
conjunction with other procedure (List in addition tocode
outpatient or ASC
for primary procedure)
Laparoscopy, surgical, splenectomy
Facility Only: $1,088 $3,794
$8,908
ROBOTIC ASSISTANCE5
Surgical techniques requiring use of robotic surgical
HCPCS II S-codes cannot be reported to Medicare. They are used
system
only by non-Medicare payers, which cover and price them according
to their own requirements.
REFERENCES:
1.Centers for Medicare & Medicaid Services. Alpha-numeric HCPCS.
2.CPT copyright 2020 American Medical Association. All rights reserved. CPT? is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein
3.Centers for Medicare & Medicaid Services. Medicare Program; CY 2021 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Quality Payment Program; Coverage of Opioid Use Disorder Services Furnished by Opioid Treatment Programs; Medicare Enrollment of Opioid Treatment Programs; Electronic Prescribing for Controlled Substances for a Covered Part D Drug; Payment for Office/Outpatient Evaluation and Management Services; Hospital IQR Program; Establish New Code Categories; Medicare Diabetes Prevention Program (MDPP) Expanded Model Emergency Policy; Coding and Payment for Virtual Check-in Services Interim Final Rule Policy; Coding and Payment for Personal Protective Equipment (PPE) Interim Final Rule Policy; Regulatory Revisions in Response to the Public Health Emergency (PHE) for COVID-19; and Finalization of Certain Provisions from the March 31st, May 8th and September 2nd Interim Final Rules in Response to the PHE for COVID-19; Final Rule, Federal Register (85 Fed. Reg. No. 248 84472- 85377) 42 CFR Parts 400, 410, 414, 415, 423, 424, and 425.
4.Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; New Categories for Hospital Outpatient Department Prior Authorization Process; Clinical Laboratory Fee Schedule: Laboratory Date of Service Policy; Overall Hospital Quality Star Rating Methodology; Physician-owned Hospitals; Notice of Closure of Two Teaching Hospitals and Opportunity To Apply for Available Slots, Radiation Oncology Model; and Reporting Requirements for Hospitals and Critical Access Hospitals (CAHs) to Report COVID-19 Therapeutic Inventory and Usage and to Report Acute Respiratory Illness During the Public Health Emergency (PHE) for Coronavirus Disease 2019 (COVID-19); Final Rule, Federal Register (85 Fed. Reg. No.249 85866-86305) 42 CFR Parts 410, 411, 412, 414, 419, 482, 485 and 512. Addendum B, AA, BB.
6
HOSPITAL INPATIENT PROCEDURE CODING
ICD-10-PCS procedure codes1 are used by hospitals to report surgeries and procedures performed in the inpatient setting.
ICD-10-PCS PROCEDURE CODE
PROCEDURE CODE DESCRIPTION
PARTIAL ADRENALECTOMY, PARTIAL EXCISION OF ADRENAL GLAND, EXCISION OF LESION OF ADRENAL GLAND
0GB20ZZ
Excision of left adrenal gland, open approach
0GB30ZZ
Excision of right adrenal gland, open approach
0GB40ZZ
Excision of bilateral adrenal glands, open approach
0GB24ZZ
Excision of left adrenal gland, percutaneous endoscopic approach
0GB34ZZ
Excision of right adrenal gland, percutaneous endoscopic approach
0GB44ZZ
Excision of bilateral adrenal glands, percutaneous endoscopic approach
TOTAL ADRENALECTOMY
0GT20ZZ
Resection of left adrenal gland, open approach
0GT30ZZ
Resection of right adrenal gland, open approach
0GT40ZZ
Resection of bilateral adrenal glands, open approach
0GT24ZZ
Resection of left adrenal gland, percutaneous endoscopic approach
0GT34ZZ
Resection of right adrenal gland, percutaneous endoscopic approach
0GT44ZZ
Resection of bilateral adrenal glands, percutaneous endoscopic approach
APPENDECTOMY
0DTJ0ZZ
Resection of appendix, open approach
0DTJ4ZZ
Resection of appendix, percutaneous endoscopic approach
CHOLECYSTECTOMY
0FT40ZZ
Resection of gallbladder, open approach
0FT44ZZ
Resection of gallbladder, percutaneous endoscopic approach
PARTIAL ESOPHAGECTOMY, PARTIAL EXCISION OF ESOPHAGUS, EXCISION OF LESION OF ESOPHAGUS
0DB10ZZ
Excision of upper esophagus, open approach
0DB20ZZ
Excision of middle esophagus, open approach
0DB30ZZ
Excision of lower esophagus, open approach
0DB40ZZ
Excision of esophagogastric junction, open approach
0DB50ZZ
Excision of esophagus, open approach
0DB14ZZ
Excision of upper esophagus, percutaneous endoscopic approach
0DB24ZZ
Excision of middle esophagus, percutaneous endoscopic approach
0DB34ZZ
Excision of lower esophagus, percutaneous endoscopic approach
0DB44ZZ
Excision of esophagogastric junction, percutaneous endoscopic approach
0DB54ZZ
Excision of esophagus, percutaneous endoscopic approach
TOTAL ESOPHAGECTOMY 0DT10ZZ
Resection of upper esophagus, open approach
0DT20ZZ
Resection of middle esophagus, open approach
0DT30ZZ
Resection of lower esophagus, open approach
0DT40ZZ
Resection of esophagogastric junction, open approach
0DT50ZZ
Resection of esophagus, open approach
0DT14ZZ
Resection of upper esophagus, percutaneous endoscopic approach
0DT24ZZ
Resection of middle esophagus, percutaneous endoscopic approach
7
ICD-10-PCS PROCEDURE CODE PROCEDURE CODE DESCRIPTION
0DT34ZZ
Resection of lower esophagus, percutaneous endoscopic approach
0DT44ZZ
Resection of esophagogastric junction, percutaneous endoscopic approach
0DT54ZZ
Resection of esophagus, percutaneous endoscopic approach
PARTIAL GASTRECTOMY, PARTIAL EXCISION OF STOMACH, EXCISION OF LESION OF STOMACH
0DB60ZZ
Excision of stomach, open approach
0DB64ZZ
Excision of stomach, percutaneous endoscopic approach
TOTAL GASTRECTOMY
0DT60ZZ
Resection of stomach, open approach
0DT64ZZ
Resection of stomach, percutaneous endoscopic approach
REPAIR OF DIAPHRAGMATIC HERNIA (HIATAL HERNIA)
Note that fundoplication for associated GERD is coded separately as below.
WITH IMPLANTATION OF MESH
Character 3 is the root operation. When mesh is used to affect the repair, the root operation is U-Supplement because U-Supplement is defined as putting on or in material, such as mesh, that physically reinforces a body part.2 The codes are then further differentiated by the type of mesh.
0BUR07Z
Supplement right diaphragm with autologous tissue substitute, open approach
0BUR0JZ
Supplement right diaphragm with synthetic substitute, open approach
0BUR0KZ
Supplement right diaphragm with nonautologous tissue substitute, open approach
0BUS07Z
Supplement left diaphragm with autologous tissue substitute, open approach
0BUS0JZ
Supplement left diaphragm with synthetic substitute, open approach
0BUS0KZ
Supplement left diaphragm with nonautologous tissue substitute, open approach
0BUR47Z 0BUR4JZ
Supplement right diaphragm with autologous tissue substitute, percutaneous endoscopic approach Supplement right diaphragm with synthetic substitute, percutaneous endoscopic approach
0BUR4KZ
0BUS47Z 0BUS4JZ
Supplement right diaphragm with nonautologous tissue substitute, percutaneous endoscopic approach Supplement left diaphragm with autologous tissue substitute, percutaneous endoscopic approach
Supplement left diaphragm with synthetic substitute, percutaneous endoscopic approach
0BUS4KZ
Supplement left diaphragm with nonautologous tissue substitute, percutaneous endoscopic approach
WITHOUT IMPLANTATION OF MESH
Character 3 is the root operation. When mesh is not used to affect the repair, the root operation is Q-Repair. This root operation is a default.
0BQR0ZZ
Repair right diaphragm, open approach
0BQRS0ZZ
Repair left diaphragm, open approach
0BQR4ZZ
Repair right diaphragm, percutaneous endoscopic approach
0BQRS4ZZ
Repair left diaphragm, percutaneous endoscopic approach
FUNDOPLICATION (EG, FOR GERD)
Character 3 is the root operation. For fundoplication, the root operation is V-Restriction because V-Restriction is defined as partially closing a lumen.2
0DV40ZZ
Restriction of esophagogastric junction, open approach
0DV44ZZ
Restriction of esophagogastric junction, percutaneous endoscopic approach
0DV48ZZ
Restriction of esophagogastric junction, via natural or artificial opening endoscopic
8
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