CPT CODES FOR PROCEDURES RELATED TO DIGESTIVE SYSTEM

CPT Codes from this section of the CPT coding system are used to report invasive and surgical procedures performed on the lips; tongue; dentoalveolar structures; palate; salivary gland; pharynx, adenoids and tonsils; esophagus;stomach; intestines; rectum; anus; liver; biliary tract; pancreas; and the abdomen, peritoneum, and omentum.

MISCELLANEOUS CODING RULES

Gastrointestinal endoscopy codes should be assigned based on the extent of visualization performed. CMS’s official guidelines for excision or destruction of a lesion are:

  1. 1.                            Use only the biopsy code if a single lesion is biopsied but not excised;
  1. 2.                            Code only for the excision if a lesion is biopsied and the remaining portion is excised;
  1. 3.                            Use the biopsy code once even if multiple biopsies are performed and none are excised; and
  1. 4.                            Use both a biopsy and excision code if each lesion is taken from different sites.

If the phrase “with or without biopsy” appears in the excision code’s narrative, do not use a separate biopsy code. Diagnostic endoscopies are included in surgical endoscopies.

For upper gastrointestinal endoscopies, choose the appropriate code from documentation indicating whether the procedure was a simple exam, a diagnostic procedure or surgical procedure. Remember that code selection is based on the procedure(s) performed and the anatomical sites through which the scope passes. For example, if the scope is passed to the esophagus only, the code would be chosen from endoscopy codes beginning with 43200. If the scope is passed through the esophagus to the stomach, duodenum and/or the jejunum, the code selection would begin at 43235.

HERNIA REPAIR

Review the patient’s age, the kind of hernia, the clinical presentation of the hernia, and method of repair documented in the medical record before assigning a hernia repair coded.

APPENDECTOMY

To code appendectomies appropriately, review the documentation for an indicated purpose for the removal. If there is none, then it is probably incidental to a more serious surgery and should not be coded.

LIPS

(For procedures on skin of lips, see 10040)

EXCISION

40490    Biopsy of lip

40500    Vermilionectomy (lip shave), with mucosal advancement.

40510    Excision of lip; transverse wedge excision, with primary closure

40520    V-excision with primary direct linear closure

(For excision of mucous lesions, see 40810-40816)

40525    Full thickness, reconstruction with local flap (eg, Estlander or fan)

40527    Full thickness, reconstruction with cross lip flap (Abbe-Estlander)

40530    Resection of lip, more than one-fourth, without reconstruction

(For reconstruction, see 13131 et seq)

REPAIR (CHEILOPLASTY)

40650    Repair lip, full thickness; vermilion only

40652    Up to half vertical height

40654    Over one-half vertical height, or complex

40700    Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral

40701    Primary bilateral, one stage procedure

40702    Primary bilateral, one of two stages

40720    Secondary, by recreation of defect and reclosure

(For bilateral procedure, report 40720with modifier -50)

(To report rhinoplasty only for nasal deformity secondary to congenital cleft lip, see 30460, 30462)

(For repair of cleft lip, with cross lip pedicle flap (Abbe-Estlander type), use 40527)

40761    with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle

(For repair cleft palate, see 42200 et seq)

(For other reconstructive procedures, see 14060, 14061, 15120-15261, 15574, 15576, 15630)

OTHER PROCEDURES

40799          Unlisted procedure, lips

VESTIBULE OF MOUTH

INCISION

40800    Drainage of abscess, cyst, hematoma, vestibule of mouth; simple

40801    Complicated

40804    Removal of embedded foreign body, vestibule of mouth; simple

40805    Complicated

40806    Incision of labial frenum (frenotomy)

EXCISION, DESTRUCTION

40808    Biopsy, vestibule of mouth

40810    Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair

40812    With simple repair

40814    With complex repair

40816    Complex, with excision of underlying muscle

40818    Excision of mucosa of vestibule of mouth as donor graft

40819    Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy)

REPAIR

40830   Closure of laceration, vestibule; 2.5 cm or less

40831   Over 2.5 cm or complex

40840   Vestibuloplasty; anterior

40842    posterior, unilateral

40843    Posterior, bilateral

40844    Entire arch

40845    Complex (including ridge extension, muscle repositioning)

(For skin grafts, see 15002)

OTHER PROCEDURES

40899    Unlisted procedure, vestibule of mouth

TONGUE AND FLOOR OF MOUTH

INCISION

41000   Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth;

41005   Sublingual, superficial

41006   Sublingual, deep, supramylohyoid

41007   Submental space

41008   Submandibular space

41009   Masticator space

41010   Incision of lingual frenum (frenotomy)

41015   Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual

41016   Submental

41017   Submandibular

41018   Masticator space

(For Frenoplasty, use 41520)

41019   Placement of needless, catheters, or other device(s) into the head and/or neck region

(percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application

(For imaging guidance, see 76942, 77002, 77012m 77021)

(For stereotactic insertion of intracranial brachytherapy radiation source, use 61770)

(For interstitial radioelement application, see 77776-77787)

EXCISION

41100          Biopsy of tongue; anterior two-third

41105          Posterior one-third

41108          Biopsy of floor of mouth

41110          Excision of lesion of tongue without closure

41112          Excision of lesion of tongue with closure; anterior two-thirds

41113          Posterior one-third

41114          With local tongue flap

(List 41114 in addition to code 41112 or 41113)

41115          Excision of lingual frenum (frenectomy)

41116          Excision, lesion of floor of mouth

41120          Glossectomy; less than one-half tongue.

41130          Hemiglossectomy

41135          Partial, with unilateral radical neck dissection

41140          Complete or total, with or without tracheostomy, without radical neck dissection

41145          Complete or total, with or without tracheostomy, with unilateral radical neck dissection

41150          Composite procedures with resection floor of mouth and mandibular resection, without

radical neck dissection.

41153          Composite procedures with resection floor of mouth, with suprahyoid neck dissection

41155          Composite procedures with resection floor of mouth, mandibular resection, and radical

neck dissection (Commando type)

REPAIR

41250          Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-third of tongue.

41251          Posterior one-third of tongue

41252          Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex.

OTHER PROCEDURES

41500          Fixation of tongue, mechanical, other than suture (eg, K-wire)

41510          Suture of tongue to lip for micrognathia (Douglas type procedure)

41512          Tongue base suspension, permanent suture technique

(For fixation of tongue, mechanical, other than suture, use 41500)

(For suture of tongue to lip for micrognathia

41520          Frenoplasty (surgical revision of frenum, eg, with Z-Plasty)

(For frenotomy, see 40806, 41010)

41530          Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session

41599          Unlimited procedure, tongue, floor of mouth

DENTOALVEOLAR STRUCTURES

INCISION

41800          Drainage of abscess, cyst, hematoma from dentoalveolar structures

41805          Removal of embedded foreign body from dentoalveolar structures; soft tissues

41806          Bone

EXCISION, DESTRUCTION

41820          Gingivectomy, excision gingiva, each quadrant

41821          Operculectomy, excision pericoronal tissues

41822          Excision of fibrous tuberosities, dentoalveolar structures

41823          Excision of osseous tuberosities, dentoalveolar structures

41825          Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair

41826          With simple repair

41827          Wiith complex repair

(For nonexcisional destruction, use 41850)

41828          Excision of hyperplastic alveolar mucosa, each quadrant (specify)

41830          Alveolectomy, including curettage of osteitis or sequestrectomy

41850          Destruction of lesion (except excision), dentoalveolar structures

OTHER PROCEDURES

41870          Periodontal mucosal grafting

41872          Gingivoplasty, each quadrant (specify)

41874          Alveoloplasty, each quadrant (specify)

(For closure of lacerations, see 40830, 40831)

(For segmental osteotomy, use 21206)

(For reduction of fractures, see 21421-21490)

41899          Unlisted procedure, dentoalveolar structures

PLATE AND UVULA

INCISION

42000          Drainage of abscess of palate, uvula

EXCISION, DESTRUCTION

42100          Biopsy of palate, uvula

42104          Excision, lesion of palate, uvula; without closure

42106          With simple primary closure

42107          With local flap closure

(For skin graft, see 14040-14300)

(For mucosal graft, used 40818)

42120          Resection of palate or extensive resection of lesion

(For reconstruction of palate with extraoral tissue, see 14040-14300, 15050, 15120,

15240, 15576)

42140          Uvulectomy, excision of uvula

42145          Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

(For removal of exostosis of the bony palate, see 21031, 21032)

42160          Destruction of lesion, palate of uvula (thermal, cryo or chemical

REPAIR

42180          Repair, laceration of palate; up to 2 cm

42182          Over 2 cm or complex

42200          Palatoplasty for cleft palate, soft and/or hard palate only

42205          Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only

42210          With bone graft to alveolar ridge (includes obtaining graft)

42215          Palatoplasty for cleft palate; major revision

42220          Secondary lengthening procedure

42225          Attachment pharyngeal flap

42226          Lengthening of palate, and pharyngeal flap

42227          Lengthening of palate, with island flap

42235          Repair of anterior palate, including vomer flap

(For repair of oronasal fistula, use 30600)

42260          Repair of nasolabial fistula

(For repair of cleft lip, see 40700 et seq)

42280          Maxillary impression for palatal prosthesis

42281          Insertion of pin-retained palatal prosthesis

OTHER PROCEDURES

42299          Unlisted procedure, palate, uvula