Digestive System

Lips  Repair
 Excision 40490-40530 o Laceration
o Biopsy o Palatoplasty for cleft palate 42200-42225
o Vermilionectomy 40500- excision of Salivary Gland and Ducts
the red (or lipstick region) margin of  Incision
the upper and lower lips. o Drainage of abscess
 Repair 40650-40761 o Sialolithotomy 42330-42340- the
o Cheiloplasty- plastic surgery of the lips physician makes an incision in the
o Repair cleft lip submandibular, sublingual, or parotid
Vestibule of mouth ducts to remove sialolith (a stone)
 Incision  Excision
o Drainage of abscess, cyst, hematome o Biopsy 42400-42405
40800-40801 o Cyst and tumor removal
o Removal of foreign body 40804-40805 o Glands removal
o Frenotomy 40806  Removal 42500-42510
 Excision/ Destruction 40808-40820  Repair 42500-42510
o Frenectomy Pharynx, adenoids and tonsils
 Repair  Incision 42700-42725
o Repair of lacerations 40830-40831  Excision, destruction
o Vestibuloplasty 40840-40845 o Biopsy
Tongue and floor of mouth o Tonsillectomy and adenoidectomy
 Incision 48420-42826
o Intraoral I&d 41000-41009  Age
o Extraoral I&D 41015-41018  Primary or secondary
o Incision of lingual frenum 41010- tongue  Modifier 52- if performed
tie unilaterally
 Excision  No modifier- if performed
o Biopsy bilaterally
o Excision of lesion  Repair
o Glossectomy 41120-41155- removal of all o Pharyngoplasty 42950- surgical repair
or part of tongue of the pharynx
Esophagus
 Repair 41250-41252
Dentoalveolar Structures  Incision
o Esophagotomy- based on approach
 Incision 41800-41806
o Cricopharyngeal myotomy 43030
 Excision, Destruction 41820-41850
 Other procedures:  Excision 43100-43135
o 41899- unlisted procedure o Lesion excision- based on approach
o Extraction of teeth- 41899 o Esophagectomy
Palate and Vulva  Endoscopy
 Incision 42000 o Watch out for indented codes
 Excision, destruction o Brackets may be useful here
o biopsy o When bleeding occurs as a result of an
o excision of lesion 42104-42107 endoscopic procedure, control of bleeding
o resection of palate
 is not reported separately during the same
operative session
o Esophagoscopy- includes examination
from the cricopharyngeus muscle up to
gastroesophageal junction
o It may also include examination of the
proximal region of the stomach via
retroflexion when performed
 Rigid, transoral 43180-43196
 Flexible, transnasal 43197-43198
 Flexible, transoral 43200-43232
o EGD (esophagostroduodenoscopy)- is a
procedure during which a small flexible
endoscope is introduced through the mouth
(or, with smaller- caliber endoscopes,
through the nose) and advances through
the pharynx, esophagus, stomach, and
duodenum
 43235
 Flexible, transoral
 Laparoscopy 43279-43284
o Surgical laparoscopy ALWAYS includes
diagnostic laparoscopy
o Esophagectomy 43286-43288
 Repair
o Esophagoplasty 43300-43314
o Esophagogastromy 43320
 Manipulation
o Dilation
Stomach
 Incision 43500-43520
 Excision
o Biopsy
o Lesion Excision
o Gastrectomy 43620-43634
 Total
 Partial
 Laparoscopy 43644-43651
o Surgical laparoscopy ALWAYS includes
diagnostic laparoscopy
Intestines
 Incision 44005-44055
 Excision
o Biopsy 44100
o Lesion Excision 44110-44111
o Enterectomy 44120-44128
o Colectomy
 Laparoscopy
 Surgical laparoscopy always includes
diagnostic laparoscopy
 Endoscopy, Small intestine
o Small intestine endoscopy 44360-44379
o Ileoscopy 44380-44386
Meckel's Diverticulum and the Mesentery
44800-44899
 a congenital pouch (diverticulum) located at
the lower (or distal) end of the small
intestine
Appendix 44900-44979
 Open 44950
o +44955
 Laparoscopy
Colon and Rectum
 Endoscopy
 Proctosigmoidoscopy- examination of the
rectum and may include examination of a
portion of the sigmoid colon
 Sigmoidoscopy- examination of the entire
rectum, sigmoid colon and may include
examination of a portion of the descending
colon
 Colonoscopy- examination of a the entire
colon, from the rectum to the cecum, and
may include examination of the terminal
ileum or small intestine to an anastomosis
 Colonoscopy through Stoma- examination
of the colon, from the colostomy stoma to
the cecum, and may include examination of
the terminal ileum or small intestine to an
anastomosis
 Colon Procedures and screening
 For colonoscopy procedures determine how
it was performed
1. Through a colostomy
2. through a colotomy
3. through the rectum
 For colorectal cancer screening see HCPCS
level II codes:
o G0104
o G0105
o G0106
 o G0120 o Exploratory laparotomy 49000
o G0121 o Drainage of abscess- open or
o G0122 percutaneous
Anus
 Hemorrhoidectomy 46221-46262  Laparoscopy 49320-49329
 Anoscopy- examination using a small, rigid, o Biopsy
tubular instrument called anoscope (also o Aspiration of cyst
called an anal speculum) o Insertion of peritoneal catheter
 46600-46615 o Surgical laparoscopy always includes
 Liver 47000-47399 diagnostic laparoscopy
 Biliary tract- 47400-47999  Hernia codes 49491-49559
 Pancreas- 48000-48999 o Age
Liver o Type of hernia (inguinal, incisional,
 Incision femoral, umbilical)
o Biopsy- needle 47000 o Reducible, strangulated or incarcerated
 +47001- when done with other major o Initial or recurrent
procedure o open or laparoscopic
o Hepatotomy 47010- the physician incises o inguinal hernia (LT/RT/50) - MESH- no
the liver to drain an abscess or a cyst, need to report separately
sometimes taking one or two stages. The
physician exposes the liver via an upper
midline incision. The cyst is incised and
suctioned with care to not contaminate the
abdomen with purulent matter
 Excision
o Biopsy- wedge 47100
o Hepatectomy- 47120-47130
Biliary Tract 47400-47999
 Gallbladder
o Cholecystectomy
o Laparoscopy 47562-47570
o Open 47600-47620
Pancreas 48000-48999
 Incision 48000-48020
 Excision
o Biopsy 48100-48102
o Lesion Removal- cyst, adenoma 48120
o Pancreatectomy 48140-48160
 Transplant
o Harvesting 48550
o Backbench work 48551-48552
o Insertion 48554
o Removal of transplanted pancreas 48556
Abdomen, peritoneum, and omentum
 Incision