General Surgery Coding Alert

Find the laparoscopic solution.

Although surgical treatment of pancreatic cancer often involves proximal pancreatectomy and other tissue excision as part of a complex Whipple procedure, surgeons might instead perform a partial distal pancreatectomy in some clinical circumstances.

Let our experts help you choose the right code for distal pancreatectomy procedures, which may vary by factors such as surgical approach, spleen involvement, and more.

Focus on Specific Example

Look at the following abbreviated operative note for pancreatic tumor to get familiar with one type of distal pancreatectomy your surgeon might perform:

Case: Insert trocar in 1 cm umbilical incision. Create pneumoperitoneum with CO₂ insufflation, and laparoscopically guide additional trocar placement for pancreatectomy. Separate tail of pancreas from gastrocolic ligament and retroperitoneal small vessels. Mobilize splenic artery and vein. Divide pancreas at distal body proximal to tumor, and suture with ligation to achieve hemostasis. Deliver distal pancreas through umbilical trocar site, and place drain along pancreas suture line through lateral trocar site to avoid pancreatic fistula.

Notice: More surgeons are choosing laparoscopic distal pancreatectomy over an open procedure based on the risk and recovery advantages of minimally invasive procedures. Plus, newer procedures may decrease the likelihood of post-op sepsis complication by implementing spleen-sparing surgery instead of the more common removal of the distal pancreas en bloc with the spleen.

Coding: Despite the rise of laparoscopic distal pancreatectomy surgeries, CPT^® does not provide a specific code for the procedure. That means you should report the above case using 48999 (Unlisted procedure, pancreas).

Do this: “You should document the details of the procedure, specifically noting key features, such as the spleen-sparing steps, then suggest a fee to the payer based on a similar procedure that has a listed code and established reimbursement value,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, national director of marketing and revenue management at FasPsych in Omaha, Nebr.

Distinguish Other Pancreatectomy Codes

Many pancreatectomy cases you face may be quite different from the preceding example, so you should be familiar with other coding options.

For open distal pancreatectomy cases, CPT^® provides the following three codes to describe the procedure:

• 48140 (Pancreatectomy, distal subtotal, with or without splenectomy; without pancreaticojejunostomy)
• 48145 (… with pancreaticojejunostomy)
• 48146 (Pancreatectomy, distal, near-total with preservation of duodenum (Child-type procedure)).

Notice that you don’t distinguish 48140 and 48145 based on whether the surgeon removes the spleen, because the codes apply with or without a splenectomy.

“Instead, you should distinguish 48140 from 48145 depending on whether the surgeon anastomoses the remaining pancreas to the jejunum for drainage,” Joy says.

Whipple is different: Surgeons commonly perform distal pancreatectomy for localized tumors in the body or tail of the pancreas, or for other conditions such as chronic pancreatitis. For more extensive pancreatic cancer, surgeons are more likely to perform a Whipple resection, which involves at least resecting the head of the pancreas, a portion of the duodenum, and joining the common bile duct to the intestine. The procedure may be even more extensive, including a partial gastrectomy, gastrojejunostomy, and more. CPT^® provides the following codes to describe various Whipple procedure configurations:

• 48150 (Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); with pancreatojejunostomy)
• 48152 (… without pancreatojejunostomy)
• 48153 (Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); with pancreatojejunostomy)
• 48154 (… without pancreatojejunostomy).

For a complete discussion of Whipple coding, see “4 Steps Focus Whipple Code Selection” in General Surgery Coding Alert Vol. 21, No. 5.