General Surgery Coding Alert

Reviewed on May 6, 2015

Coding for stomach surgery requires detailed procedural notes and familiarity with related anatomy and medical terminology. Many types of procedures, each with several subcategories, may be differentiated in part or entirely by anatomy, notes Marcella Bucknam, CPC, coordinator of the health information management program at Clarkson College in Omaha, Neb. 
 
CPT^® includes codes for partial gastrectomies that are performed in the proximal stomach and the distal stomach. Other codes specifically involve the pyloric valve or sphincter through which digested food must pass before entering the small bowel, she says. 
 
Answering a few simple questions based on the surgeon's notes can greatly simplify selecting or verifying the correct code, Bucknam adds.

1. Did the procedure involve incision or excision? CPT^® includes five stomach incision codes, four of which describe gastrotomies (43500-43510). The fifth code, 43520, describes a procedure whereby the pyloric muscle is cut to prevent it from contracting says M. Trayser Dunaway, MD, FACS, a general surgeon in private practice in Camden S.C. This procedure is often performed in children with pyloric stenosis or used with ulcer surgery in conjunction with vagotomy.
 
CPT® also lists stomach excision codes (43600 is no longer valid, see 43605-43641).

2. If the procedure involved excision, was it a biopsy or the excision of a tumor or ulcer? The first four stomach excision codes involve biopsies or tumor excisions. Use excision codes based on whether the tumor is benign (43610) or malignant (43611). Use CPT^® Code 43610 when an ulcer is removed.

3. If gastrectomy was performed, was it total or partial? CPT^® lists three gastrectomy codes used when the entire stomach is removed. Each describes a different procedure to resolve the gastrectomy: anastomosis to connect the esophagus to the small intestine (43620), Roux-en-Y reconstruction (43621), and creating an intestinal pouch to connect the esophagus and the small bowel (43622).
 
4. If partial gastrectomy was performed, was it distal or proximal? Coding partial gastrectomy can be more complicated as it can be either distal or proximal. CPT^®'s distal partial gastrectomy series is broken down in roughly the same manner as the total gastrectomy series: 43631 (Gastrectomy partial distal; with gastroduodenostomy), 43632 ( with gastrojejunostomy), 43633 ( with Roux-en-Y reconstruction), and 43634 ( with formation of intestinal pouch).

5. Was a vagotomy performed? Vagotomy can prevent the stomach from producing acid that can lead to ulcer disease can report vagotomy separately as +43635 when performed during partial distal gastrectomy. 
 
"The surgeon's notes need to specify whether the procedure was proximal or distal," Bucknam says. "If the surgeon reports +43635 with 43631, for example, but the notes do not mention directly or indirectly that a distal gastrectomy was performed, the coder should ask the surgeon to revise the note before the claim is submitted." 
 
Code +43635 is an add-on code; thus it has already been reduced and is not subject to multiple- procedure guidelines. 
 
This means it should not be further reduced in value when it is reported with a partial distal gastrectomy and should be paid at 100 percent of the carrier's approved amounts.
 
Although CPT^® also lists several vagotomy "separate procedure" codes you should not always separately report a vagotomy with other procedures. Medicare’s Correct Coding Initiative Policy Manual states, “The vagotomy CPT® codes (e.g., 43635-43641, 64755-64760) are not separately reportable with esophageal or gastric procedures that include vagotomy as part of the service. For example, the esophagogastrostomy procedure described by CPT® code 43320 includes a vagotomy if performed. The vagotomy procedures are mutually exclusive, and only one vagotomy procedure code may be reported at a patient encounter.” (chapter 6, January 2015 update).

 
The final two codes in the stomach excision section describe vagotomies typically performed on infants with pyloric stenosis, Dunaway says. 
 
Report 43640 for a vagotomy that requires pyloromyotomy but does not involve gastrectomy; use 43641 for a highly selective parietal cell vagotomy.