General Surgery Coding Alert

Identify approach, excisions, and resections.

Surgical treatment for pancreatic cancer might challenge you with coding the complicated Whipple procedure.

Problem is, you might not even see that name in the op note, instead confronting a list of seemingly disparate procedures like duodenectomy, gastrojejunostomy, and choledochoenterostomy.

Here’s why: The pancreas is closely associated with other organs, so removing part of the pancreas necessarily involves removing all or part of other organs such as the gallbladder, part of the small intestine, common bile duct, and stomach. Following these resections and excisions, the surgeon must reconnect the organs to allow for normal digestive function.

Let our experts break Whipple procedure coding down for you into four easy steps so you can sail through these claims with ease.

Step 1: Nail the Terminology

A Whipple by any other name would take the same code(s) — and those names might include pancreaticoduodenectomy, pancreatoduodenectomy, pancreatectomy with duodenectomy, Kausch or Kausch-Whipple procedure, or pylorus-sparing pancreaticoduodenectomy (Traverso-Longmire procedure).

Mandatory: Regardless of the name, all Whipple procedures involve removing the head of the pancreas (pancreatectomy) and at least a portion of the duodenum (duodenectomy), and joining of the common bile duct to the intestine (choledochoenterostomy), according to Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

Maybe more: A Whipple procedure may also include removing a portion of the stomach (partial gastrectomy), and creating a link between the stomach and the jejunum (gastrojejunostomy); the duodenum and the jejunum(duodenojejunostomy); or the jejunum and a pancreatic duct, cyst or fistula (pancreatojejunostomy).

Even when the name “Whipple” is nowhere in sight, if you face an op note that describes all the “mandatory” steps and possibly some of the “maybe more” steps, you should turn to the Whipple codes rather than individually reporting each procedure.

The possible code choices include the following:

• 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).

Caveat: Surgeons may rarely perform a laparoscopic Whipple resection, and without a specific CPT^® code for that procedure, you would need to turn to 49329 (Unlisted laparoscopy procedure, abdomen, peritoneum and omentum) to report that service.

Step 2: Determine Extent of Duodenectomy, Gastrectomy

Because the two Whipple code families divide over the difference between a total or partial duodenectomy, you should scan the op note to see if the surgeon removed all or a portion of the duodenum, which is the first (proximal) section of the small intestine.

The 48150 family describes total duodenectomy, while the 48153 family describes a partial duodenectomy. The 48150 family also describes a partial gastrectomy.

Tip: If the op note describes a partial gastrectomy and gastrojejunostomy, the procedure must have included a total duodenectomy.

On the other hand, the pylorus-sparing procedure involves anastomosing the duodenum to the jejunum rather than the stomach. If the op note describes a duodenojejunostomy, that’s evidence of a partial duodenectomy.

“Surgeons perform this type of Whipple procedure to preserve the pylorus, which is the valve that allows for normal gastric emptying,” explains Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, vice president for revenue management with Encounter Telehealth in Omaha, Nebr. The pylorus-sparing procedures are more common, but surgeons can use this method only when the pancreatic cancer doesn’t involve the stomach and the associated lymph nodes appear normal.

You’ll notice that all the Whipple codes include choledochoenterostomy, which is the surgical linkage of the common bile duct and a portion of the intestine. You should notice this work described in the op note, but it shouldn’t change your code selection.

Step 3: Look for Pancreatojejunostomy

During a Whipple procedure, the surgeon may create an artificial opening between the pancreas and the jejunum, which is an anastomosis procedure called pancreatojejunostomy. The op note will describe formation of a duct, fistula, or cyst between the organs.

The pancreatojejunostomy is a reconstruction method intended to decrease postoperative complications such as pancreatic fistulas.

Whether the surgeon performs a pancreatojejunostomy is the final feature that distinguishes your code choice within each Whipple code family. The parent codes each include pancreatojejunostomy (48150 and 48153), while the indented codes in each family describe procedures without the pancreatojejunostomy (48152 and 48154).

Step 4: Beware Bundling Restrictions

Because a Whipple procedure involves various excisions, resections, and anastomoses, you’ll need to be careful to not “double-dip” by billing codes that the Whipple procedure includes.

For instance: A Whipple procedure usually includes removing the gall bladder, so you shouldn’t separately code that work.

In fact, the national Correct Coding Initiative (CCI) bundles 47600 (Cholecystectomy) as a column 2 code with the Whipple procedure codes with a modifier indicator of “0,” meaning that you should not report the codes together under any circumstances.

Similarly: The Whipple procedure described by codes 48150 and 48152 include partial gastrectomy with gastrojejunostomy, and CCI bundles 43632 (Gastrectomy, partial, distal; with gastrojejunostomy) as a column 2 code with those Whipple codes, also with a “0” modifier indicator.

Whipple procedures often include peripancreatic lymphadenectomy, but CCI edits restrict billing 48150-48154 with +38747 (Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-aortic and vena caval nodes (List separately in addition to code for primary procedure)).

Also, the surgeon may often perform a diagnostic laparoscopy prior to the Whipple procedure to visualize the extent of the cancer, and CCI edits bundle 49320 (Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)) as a column 2 code with 48150-48154.