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⚖️ Bariatric Surgery
Weight-Loss & Metabolic
Roux-en-Y Gastric Bypass (RYGB)
Gold standard bariatric procedure
Creates a small stomach pouch (~30mL) connected directly to the mid-jejunum, bypassing ~95% of the stomach and the duodenum to limit food intake and reduce caloric absorption.
Why It's Done
Indicated for morbid obesity (BMI ≥40) or BMI ≥35 with serious comorbidities (Type 2 DM, HTN, sleep apnea, GERD). Produces 60–80% excess weight loss at 12–18 months. Also treats poorly controlled GERD and Type 2 Diabetes.
Surgical Steps
1
General anesthesia; patient supine in reverse Trendelenburg
2
Trocar placement (5–6 ports for laparoscopic approach)
3
Creation of ~30mL gastric pouch by transecting proximal stomach with linear stapler
4
Roux limb created by dividing jejunum ~30–50cm from Treitz; alimentary limb 75–150cm
5
Gastrojejunostomy (pouch to Roux limb) — linear or circular stapled
6
Jejunojejunostomy closing the Y-limb; mesenteric defects closed
Roux-en-Y Gastric Bypass — anatomical schematic showing gastric pouch, Roux limb routing, and common channel
Primary CPT Codes
43644
Laparoscopic RYGB
43846
Open RYGB
43644 + S2900
Robotic RYGB
| CPT | Description | Approach | Global Days |
|---|---|---|---|
| 43644 | Laparoscopic gastric bypass with Roux-en-Y gastroenterostomy | Laparoscopic | 90 |
| 43846 | Gastric bypass with Roux-en-Y gastroenterostomy, open | Open | 90 |
| 43645 | Laparoscopic gastric bypass; with small intestine reconstruction | Laparoscopic | 90 |
| 43770 | Lap gastric restrictive procedure with band placement | Laparoscopic | 90 |
| 43999 | Unlisted laparoscopic bariatric procedure | Various | 0 |
Common ICD-10 Diagnosis Codes
E66.01E66.09E11.9
I10G47.33K21.0
M79.3E78.5E11.65
| ICD-10 | Description |
|---|---|
| E66.01 | Morbid (severe) obesity due to excess calories |
| E66.09 | Other obesity due to excess calories |
| E11.9 | Type 2 DM without complications |
| I10 | Essential (primary) hypertension |
| G47.33 | Obstructive sleep apnea (adult) |
| K21.0 | GERD with esophagitis |
Medical Necessity Not MetBMI documentation missing or <40 without qualifying comorbidity. Requires 6-month supervised diet program documentation for most payers.
Prior Authorization Required / ExpiredSurgery date outside auth window or auth obtained for different CPT (e.g., sleeve authorized instead of RYGB).
Experimental / InvestigationalRobotic approach (S2900 modifier) not covered by all payers; robotic RYGB still considered investigational by some commercial plans.
Timely FilingClaims submitted beyond payer's filing limit (varies 90 days – 1 year). Particularly common when claim rejections cause resubmission delays.
Failure of Conservative TreatmentPayer requires documented failure of medically supervised weight loss program ≥6 months; inadequate documentation triggers denial.
Out-of-Network / Facility MismatchSurgeon in-network but facility out-of-network, or vice versa. Common when surgeons operate at multiple hospitals.
Sleeve Gastrectomy
Most common bariatric procedure in US
Removes ~80% of the stomach along the greater curvature, creating a sleeve-shaped stomach (~100–150mL). Reduces ghrelin production and food capacity without intestinal bypass.
Why It's Done
Indicated for BMI ≥40 or BMI ≥35 with comorbidities. Preferred when RYGB is too risky (liver disease, prior GI surgery). Produces 50–60% excess weight loss. Also performed as first-stage procedure before RYGB or SADI-S in super-obese patients.
Surgical Steps
1
Trocar placement; 36Fr bougie inserted transorally to calibrate sleeve width
2
Dissection of greater omentum 4–6cm proximal to pylorus
3
Sequential firing of linear stapler along bougie from antrum to angle of His
4
Resected stomach removed through 12mm trocar site
5
Staple line reinforced with oversewing or buttress material; methylene blue leak test
Sleeve Gastrectomy — ~80% gastric resection along greater curvature; staple line calibrated with 36Fr bougie
43775
Lap Sleeve Gastrectomy
43775 + S2900
Robotic Sleeve
| CPT | Description | Notes |
|---|---|---|
| 43775 | Laparoscopic sleeve gastrectomy | Primary code |
| 43843 | Gastric restrictive procedure, without gastric bypass — open | Open approach |
| S2900 | Surgical techniques using robotic systems | Add-on modifier |
| 43999 | Unlisted laparoscopic bariatric | If no specific code |
E66.01E66.09E11.9I10G47.33M81.0E78.5
| ICD-10 | Description |
|---|---|
| E66.01 | Morbid obesity due to excess calories |
| E66.09 | Other obesity |
| E11.9 | Type 2 DM without complications |
| G47.33 | Obstructive sleep apnea |
Medical NecessityBMI <40 without documented comorbidities; missing weight history or nutrition program records.
Auth for Wrong ProcedureAuth obtained for RYGB but patient/surgeon chose sleeve; requires separate auth.
ASC Not ApprovedSome payers require hospital setting for BMI >50 or with severe comorbidities; ASC claim denied.
BundlingHiatal hernia repair (43281) billed same day often bundled by payer; requires modifier 59 or XS.
Laparoscopic Adjustable Gastric Band (LAGB)
Reversible restrictive procedure
Adjustable silicone band placed around upper stomach creating a ~15–20mL pouch. Band tightened/loosened via subcutaneous port with saline injections to control restriction level.
Why It's Done
BMI ≥40 or BMI 30–40 with serious comorbidities. FDA-approved down to BMI 30 with ≥1 comorbidity. Lowest risk bariatric option; preferred in high-risk surgical patients. However, declining in use due to high reoperation and band removal rates.
Key Steps
1
Band placed via pars flaccida technique around upper stomach
2
Band locked in place; tubing tunneled subcutaneously to port
3
Port sutured to anterior rectus fascia; initial fill deferred 4–6 weeks
43770
Lap Band Placement
43771
Lap Band Adjustment
43774
Band Removal
| CPT | Description |
|---|---|
| 43770 | Laparoscopic placement of adjustable gastric restrictive device |
| 43771 | Laparoscopic revision of adjustable device port / tubing |
| 43772 | Laparoscopic removal of adjustable device only |
| 43773 | Laparoscopic removal and replacement of adjustable device |
| 43774 | Laparoscopic removal of adjustable device and subcutaneous port |
| 43886 | Gastric restrictive procedure, open; revision of subcutaneous port |
E66.01E66.09I10E11.9G47.33
Not Covered by PayerMany commercial insurers and Medicare now restrict or exclude LAGB coverage due to high failure rates.
Global Period — Band AdjustmentAdjustments (43771) within 90-day global period of placement (43770) denied as inclusive. Bill separately after global period.
Missing Device InvoiceBand device cost requires separate implant invoice; claim denied without documentation of implant cost.
Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
Most effective for super-obesity
Combines sleeve gastrectomy with significant small bowel bypass. Alimentary limb ~250cm; common channel only ~75–100cm. Highest weight loss (70–80% EWL) with significant malabsorption risk.
Why It's Done
BMI ≥50 (super-obesity), failed prior bariatric surgery, or severe Type 2 DM requiring maximal metabolic effect. Also SADI-S (single anastomosis duodeno-ileal bypass with sleeve) is a simpler variant increasingly replacing classic BPD/DS.
Key Risks
Severe malnutrition, protein deficiency, fat-soluble vitamin deficiency (A, D, E, K), metabolic bone disease. Requires lifelong supplementation and close follow-up.
| CPT | Description |
|---|---|
| 43845 | Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenojejunostomy (duodenal switch) |
| 43775 | Laparoscopic sleeve gastrectomy (sleeve component, if staged) |
| 43999 | Unlisted laparoscopic bariatric procedure (SADI-S) |
E66.01E11.65E66.09E78.5M81.0
No Specific CPT — SADI-SSADI-S billed as 43999 (unlisted); payer requires operative report and peer-to-peer review. Frequently denied as experimental.
Medical NecessityPayers require higher BMI threshold (≥50) or extensive documentation of failed prior bariatric surgery.
Revisional Bariatric Surgery
Conversion / Re-do procedures
Conversion of prior bariatric procedure due to insufficient weight loss, weight regain, or complications. Includes band-to-sleeve, band-to-bypass, sleeve-to-bypass conversions.
Why It's Done
Insufficient weight loss (<50% EWL), weight regain >50% of lost weight, anastomotic stricture, pouch dilation, band erosion/slippage, GERD unresponsive to sleeve. Most common conversion: sleeve-to-RYGB and band-to-sleeve.
| CPT | Description |
|---|---|
| 43848 | Revision, open, gastric restrictive procedure |
| 43886 | Gastric restrictive procedure; revision of subcutaneous port component only |
| 43888 | Gastric restrictive procedure; removal and replacement of adjustable gastric device |
| 43999 | Unlisted laparoscopic procedure (sleeve-to-bypass conversion) |
| 43644 | Conversion to RYGB (laparoscopic) |
Z98.84T85.518AE66.01K21.0K31.1
| ICD-10 | Description |
|---|---|
| Z98.84 | Bariatric surgery status |
| T85.518A | Breakdown of gastric band prosthesis |
| K31.1 | Adult hypertrophic pyloric stenosis |
Not Medically NecessaryPayer requires >2 years post-primary procedure and documented weight regain with comorbidity recurrence.
Unlisted Code — No Fee Schedule43999 submitted without operative report; payer returns to provider for pricing determination.
Bundled ServicesBand removal (43774) and sleeve gastrectomy (43775) billed same day; payer bundles — use modifier 59.
Intragastric Balloon (IGB)
Non-surgical endoscopic weight loss
Endoscopically placed fluid-filled silicone balloon in the stomach (400–700mL) for 6 months to reduce functional stomach volume. Orbera and Obalon are common systems. BMI 30–40.
Why It's Done
For patients with BMI 30–40 not qualifying for surgical bariatric procedures or unwilling to undergo surgery. Bridge therapy before major surgery in super-obese patients. Average 10–15% total body weight loss over 6 months.
| CPT | Description |
|---|---|
| 43999 | Unlisted procedure, esophagus / stomach (balloon placement) |
| 43239 | EGD with injection — sometimes used for swallowable balloon |
⚠️ No specific CPT code for IGB; typically billed as unlisted or denied as cosmetic by most payers.
Not Covered — Cosmetic ExclusionNearly all commercial payers and Medicare exclude IGB as cosmetic/experimental. Patient must pay out-of-pocket.
Unlisted Code Denial43999 consistently denied pending documentation; peer-to-peer rarely successful for IGB.
Hiatal Hernia Repair + Anti-Reflux (Concurrent Bariatric)
Add-on to bariatric surgery
Crural repair (43281) performed concurrently with sleeve gastrectomy or RYGB. Present in ~30–40% of morbidly obese patients. Fundoplication (Nissen/Toupet) may be added if converting sleeve to bypass.
| CPT | Description |
|---|---|
| 43281 | Laparoscopic repair of paraesophageal hernia, without fundoplasty |
| 43282 | Laparoscopic repair of paraesophageal hernia, with fundoplasty |
| 43280 | Laparoscopic fundoplasty (Nissen or Toupet) |
✅ Bill 43281 with modifier 59/XS when performed concurrently with 43775 or 43644.
K44.9K21.0K22.0K44.0
Bundled with Primary BariatricPayers bundle 43281 into 43775/43644 global; requires modifier 59 + separate diagnosis justifying additional procedure.
🏥 General Surgery
ASC & Hospital
Laparoscopic Cholecystectomy
#1 most common general surgery procedure
Removal of the gallbladder via 4 laparoscopic ports. Indicated for symptomatic cholelithiasis, acute cholecystitis, biliary dyskinesia, choledocholithiasis, and gallstone pancreatitis.
Why It's Done
Symptomatic gallstones, acute cholecystitis (emergent), biliary colic, gallstone pancreatitis, biliary dyskinesia (EF <35%). Gold standard since 1987. 90%+ of cholecystectomies performed laparoscopically; open conversion rate ~5%.
Surgical Steps
1
Umbilical port (10–12mm) + 3 additional 5mm ports; CO₂ insufflation to 15mmHg
2
Dissection of hepatocystic triangle; critical view of safety (CVS) achieved
3
Cystic duct and cystic artery clipped x2 proximally, x1 distally; divided
4
Gallbladder dissected off liver bed with electrocautery; retrieved in bag
5
Hemostasis; fascial closure at 10mm port site
Laparoscopic Cholecystectomy — Critical View of Safety with cystic duct and artery identification prior to clipping
47562
Lap Cholecystectomy
47563
+ Cholangiography
47600
Open Cholecystectomy
| CPT | Description | Notes |
|---|---|---|
| 47562 | Laparoscopic cholecystectomy | Standard lap approach |
| 47563 | Laparoscopic cholecystectomy with cholangiography | IOC performed |
| 47564 | Laparoscopic cholecystectomy with exploration of CBD | Lap CBD exploration |
| 47600 | Cholecystectomy, open | Open approach |
| 47605 | Cholecystectomy, open, with cholangiography | Open + IOC |
| 47610 | Open cholecystectomy with exploration of CBD | Open + CBD |
| 47612 | Open cholecystectomy with choledochoenterostomy | Biliary bypass |
K80.20K80.00K81.0K81.1K82.8K85.10K80.50
| ICD-10 | Description |
|---|---|
| K80.20 | Calculus of gallbladder without cholecystitis, without obstruction |
| K81.0 | Acute cholecystitis |
| K81.1 | Chronic cholecystitis |
| K82.8 | Biliary dyskinesia |
| K85.10 | Biliary acute pancreatitis |
Medical Necessity — DyskinesiaEF ≥35% without symptoms; requires documented biliary colic + nuclear medicine HIDA scan with EF <35% and symptom reproduction.
Cholangiography Bundled47563 components (cholangiography) sometimes bundled by NCCI edits with concurrent ERCP or CBD exploration.
Emergent vs Elective AuthElective cases denied if auth not obtained pre-op; emergent admissions (acute cholecystitis) generally exempt but documentation must support emergent nature.
ASC Not AppropriateAcute cholecystitis, fever, leukocytosis — payer denies ASC claim; requires hospital admission setting.
Appendectomy
Emergent & elective appendix removal
Removal of the vermiform appendix. Emergent for acute appendicitis; elective for recurrent appendicitis or incidental removal. 3-port laparoscopic technique is standard; open (McBurney incision) for perforated/complicated cases.
Why It's Done
Acute appendicitis (most common abdominal surgical emergency), perforated appendix with peritonitis, appendiceal mass, appendiceal neoplasm (carcinoid, mucocele). Non-operative management (antibiotics) now an option for uncomplicated cases but surgery remains definitive.
Key Steps
1
3 trocars: umbilical 10–12mm, suprapubic 5mm, left lower quadrant 5mm
2
Appendix identified; mesoappendix dissected and divided
3
Base of appendix ligated with endoloop x2 or stapled with 30mm stapler
4
Appendix removed in retrieval bag; copious irrigation if perforated
44950
Open Appendectomy
44970
Laparoscopic Appendectomy
| CPT | Description |
|---|---|
| 44950 | Appendectomy, open |
| 44960 | Appendectomy, open; for ruptured appendix with abscess or generalized peritonitis |
| 44970 | Laparoscopic appendectomy |
K37K35.20K35.21K35.89K36
| ICD-10 | Description |
|---|---|
| K37 | Unspecified appendicitis |
| K35.20 | Acute appendicitis with generalized peritonitis, without abscess |
| K35.21 | Acute appendicitis with generalized peritonitis, with abscess |
| K35.89 | Other and unspecified acute appendicitis |
Incidental Appendectomy BundledAppendectomy performed during another abdominal surgery (e.g., colectomy) — bundled by payer; bill 44950 with modifier 59 only if separately documented indication exists.
Wrong CPT — Perforated44950 used when 44960 appropriate (ruptured appendix); undercoding or overcoding creates audit flags and denial.
Pathology MismatchClaim denied if pathology report returns normal appendix without documented surgical decision-making rationale pre-operatively.
Hernia Repair
Inguinal, Ventral, Incisional, Umbilical, Femoral
Surgical reduction and repair of hernial defect with or without mesh. Inguinal is most common (66% of all hernias). Laparoscopic TEP/TAPP for inguinal; IPOM or rTAPP for ventral/incisional hernias.
Why It's Done
Symptomatic hernia (pain, incarceration risk), incarcerated hernia (emergent), recurrent hernia, cosmetic/functional impairment. 1 million hernia repairs annually in the US. Open Lichtenstein (mesh tension-free) is standard for inguinal; TEP (totally extraperitoneal) for bilateral inguinal.
Types
- Inguinal (indirect/direct): Most common; through inguinal canal
- Femoral: Through femoral canal; higher strangulation risk
- Umbilical: Through umbilical ring; <2cm often primary repair
- Ventral/Incisional: Through prior incision; mesh repair standard
- Epigastric: Midline above umbilicus
- Parastomal: Adjacent to stoma
| CPT | Description |
|---|---|
| 49505 | Open repair initial inguinal hernia, age ≥5; reducible |
| 49507 | Open repair initial inguinal hernia, incarcerated/strangulated |
| 49520 | Open repair recurrent inguinal hernia, reducible |
| 49521 | Open repair recurrent inguinal hernia, incarcerated |
| 49560 | Open repair initial incisional/ventral hernia, reducible |
| 49561 | Open repair initial incisional hernia, incarcerated |
| 49650 | Laparoscopic repair initial inguinal hernia |
| 49651 | Laparoscopic repair recurrent inguinal hernia |
| 49652 | Laparoscopic repair ventral hernia (reducible) |
| 49653 | Laparoscopic repair ventral hernia (incarcerated) |
| 49654 | Laparoscopic repair incisional hernia (reducible) |
| 49655 | Laparoscopic repair incisional hernia (incarcerated) |
| 49659 | Unlisted laparoscopic hernia repair procedure |
| 49585 | Open repair umbilical hernia, age ≥5; reducible |
K40.90K40.91K40.00K43.9K43.0K42.9K41.90
| ICD-10 | Description |
|---|---|
| K40.90 | Unilateral inguinal hernia, without obstruction, reducible |
| K40.00 | Bilateral inguinal hernia with obstruction, not specified as recurrent |
| K43.0 | Incisional hernia with obstruction, without gangrene |
| K43.9 | Ventral hernia, reducible |
| K42.9 | Umbilical hernia, reducible |
Reducible vs Incarcerated MismatchCPT 49507 (incarcerated) billed but operative note describes reducible hernia; downcoded to 49505 on audit.
Mesh Not Separately BillableMesh (A4561/C1781) denied unless ASC bill to facility; surgeon cannot separately bill mesh cost.
Bilateral Hernia — Modifier 50Bilateral inguinal repair requires modifier 50 on 49505/49650; missing modifier causes 50% payment denial on second side.
Robotic Approach — S2900Robotic hernia repair (S2900 modifier) denied by Medicare; commercial payers vary. Document medical necessity for robotic approach.
Recurrent vs Initial49520 (recurrent) requires documentation of prior repair; denied if prior surgery not documented in record.
Colectomy
Partial & Total Colon Resection
Resection of a portion or the entire colon. Includes right hemicolectomy, left hemicolectomy, sigmoid colectomy, total abdominal colectomy, and proctocolectomy. Primary anastomosis or diverting ostomy created.
Why It's Done
Colorectal cancer, diverticulitis (recurrent or complicated), Crohn's disease, ulcerative colitis, colon polyps not amenable to endoscopic removal, ischemic colitis, volvulus, trauma. Laparoscopic colectomy is associated with faster recovery, less pain, and shorter hospital stay.
Types
- Right hemicolectomy: Cecum, ascending colon, hepatic flexure; ileocolic anastomosis
- Left hemicolectomy: Descending colon; colorectal anastomosis
- Sigmoid colectomy: Sigmoid; most common for diverticulitis
- Total abdominal colectomy: Entire colon; IBD, FAP
- Proctocolectomy: Colon + rectum; UC with ileal pouch (J-pouch)
| CPT | Description |
|---|---|
| 44140 | Open colectomy, partial, with anastomosis |
| 44141 | Open colectomy, partial, with skin-level cecostomy or colostomy |
| 44160 | Open colectomy, partial, with removal of terminal ileum; with ileocolostomy |
| 44204 | Laparoscopic colectomy, partial, with anastomosis |
| 44205 | Laparoscopic colectomy, partial, with removal of terminal ileum |
| 44206 | Laparoscopic colectomy, partial, with end colostomy |
| 44210 | Laparoscopic total abdominal colectomy with proctectomy |
| 44211 | Laparoscopic total abdominal colectomy with ileal-pouch |
| 44212 | Laparoscopic total abdominal colectomy with ileostomy |
C18.9K57.30K51.90K50.90K63.5K55.049
| ICD-10 | Description |
|---|---|
| C18.9 | Malignant neoplasm of colon, unspecified |
| K57.30 | Diverticulosis of large intestine without perforation or abscess, without bleeding |
| K51.90 | Ulcerative colitis, unspecified, without complications |
| K50.90 | Crohn's disease of small intestine, unspecified |
Incorrect CPT SpecificityOpen vs laparoscopic codes have different reimbursement; conversion to open mid-surgery requires modifier 22 (increased complexity), not a different CPT retroactively.
Staging Surgery BundledTwo-stage colectomy (resection + reversal) — each stage is separately billable, but reversal within global period of original resection may be bundled.
Ostomy Creation BundledOstomy creation (colostomy/ileostomy) is included in colectomy CPT codes and cannot be separately billed.
Thyroidectomy
Partial, Hemi- & Total Thyroidectomy
Surgical removal of part or all of the thyroid gland. Total thyroidectomy for cancer or Graves' disease; hemi- or lobectomy for single-lobe nodule or follicular adenoma. Parathyroid preservation and RLN monitoring are critical.
60240
Total Thyroidectomy
60220
Hemithyroidectomy
| CPT | Description |
|---|---|
| 60210 | Partial thyroid lobectomy, unilateral; with or without isthmusectomy |
| 60220 | Total thyroid lobectomy, unilateral (hemithyroidectomy) |
| 60225 | Total thyroid lobectomy + isthmusectomy |
| 60240 | Total thyroidectomy |
| 60252 | Total thyroidectomy for malignancy with limited neck dissection |
| 60254 | Total thyroidectomy for malignancy with radical neck dissection |
| 60500 | Parathyroidectomy or exploration; initial |
C73E05.00E04.9D34E04.2E21.0
| ICD-10 | Description |
|---|---|
| C73 | Malignant neoplasm of thyroid gland |
| E05.00 | Thyrotoxicosis (Graves' disease) without thyrotoxic crisis |
| E04.9 | Nontoxic goiter, unspecified |
| D34 | Benign neoplasm of thyroid gland |
Benign Nodule — Medical NecessityThyroidectomy for benign nodule denied unless documented compressive symptoms (dysphagia, dyspnea), failed RAI, or Bethesda ≥IV cytology on FNA.
Intraoperative Neuromonitoring (IONM)Neuromonitoring (95940) billed separately; bundled by some payers into thyroidectomy global. Requires documentation of bilateral procedures or oncologic case.
Parathyroid Auto-transplant Bundled64999 (parathyroid auto-transplant) during thyroidectomy frequently bundled; requires modifier 59 and separate operative documentation.
Hemorrhoidectomy
Excisional & stapled hemorrhoid surgery
Surgical excision of internal and/or external hemorrhoids. Excisional hemorrhoidectomy (Milligan-Morgan, Ferguson), stapled hemorrhoidopexy (PPH), and THD (transanal hemorrhoidal dearterialization) are main techniques.
| CPT | Description |
|---|---|
| 46250 | Hemorrhoidectomy, external, 2 or more columns/groups |
| 46255 | Hemorrhoidectomy, internal and external, simple |
| 46257 | Hemorrhoidectomy, internal and external, with fissurectomy |
| 46258 | Hemorrhoidectomy, internal and external, with fistulectomy |
| 46260 | Hemorrhoidectomy, internal and external, complex / extensive |
| 46500 | Injection of sclerosing solution, hemorrhoids |
| 46930 | Destruction of internal hemorrhoid(s) by thermal energy |
| 46947 | Hemorrhoidopexy (stapled hemorrhoidopexy — PPH) |
K64.1K64.2K64.3K64.4K64.8
| ICD-10 | Description |
|---|---|
| K64.0 | First degree hemorrhoids |
| K64.1 | Second degree hemorrhoids |
| K64.2 | Third degree hemorrhoids |
| K64.3 | Fourth degree hemorrhoids |
| K64.4 | Residual hemorrhoidal skin tags |
Cosmetic Exclusion — Skin Tags46220 (skin tag removal) frequently denied as cosmetic; must document bleeding, thrombosis, or significant symptoms.
Conservative Treatment Not ExhaustedPayers require documented failure of dietary modification, sitz baths, topical therapy, and rubber band ligation before approving excisional hemorrhoidectomy.
PPH — Stapled Not Covered46947 (stapled hemorrhoidopexy) denied by some payers citing insufficient long-term evidence; verify coverage before performing.
Anti-Reflux Surgery (Nissen/Toupet Fundoplication)
GERD surgical treatment
Wrapping the gastric fundus 360° (Nissen) or 270° (Toupet) around the lower esophagus to strengthen the LES. Standard surgical treatment for refractory GERD, Barrett's esophagus, or hiatal hernia with GERD.
| CPT | Description |
|---|---|
| 43280 | Laparoscopic fundoplasty (Nissen or Toupet) |
| 43324 | Esophagogastric fundoplasty, open (Nissen) |
| 43325 | Esophagogastric fundoplasty with diaphragm repair |
| 43327 | Esophagogastric fundoplasty with Collis gastroplasty |
K21.0K21.9K22.10J68.0K44.9
| ICD-10 | Description |
|---|---|
| K21.0 | GERD with esophagitis |
| K21.9 | GERD without esophagitis |
| K22.10 | Ulcer of esophagus without bleeding |
| K44.9 | Diaphragmatic hernia, reducible |
PPI Trial Not DocumentedPayers require ≥6 months of high-dose PPI therapy failure documented before surgical GERD treatment is authorized.
Manometry / pH Study RequiredPre-op pH monitoring (Bravo/Impedance) and esophageal manometry required by most payers; surgery denied without documentation.
Hiatal Repair Bundled43281 bundled with 43280 by some payers; use modifier 59 when hiatal defect requires separate repair beyond fundoplication.
Sigmoid / Diverticular Disease Resection
Hartmann's procedure & reversal
Sigmoid resection for recurrent diverticulitis or complicated diverticulitis (perforation, abscess, fistula). Hartmann's procedure (end colostomy + rectal stump) in unstable patients; primary anastomosis in stable patients.
| CPT | Description |
|---|---|
| 44143 | Open colectomy, partial, with end colostomy/closure of distal segment (Hartmann's) |
| 44144 | Open colectomy, partial, with resection, with colostomy/ileostomy + closure of other end |
| 44206 | Laparoscopic colectomy, partial, with end colostomy |
| 44207 | Laparoscopic colectomy, partial, with anastomosis with coloproctostomy |
| 44227 | Laparoscopic closure of enterostomy (Hartmann reversal) |
K57.20K57.21K57.32K57.40K57.80
Conservative Treatment RequirementElective resection after 2 episodes of uncomplicated diverticulitis; payer requires documentation of both episodes and failed antibiotic therapy.
Hartmann Reversal Timing44227 denied if performed within global period of original Hartmann procedure (44143); must wait 90 days.
Splenectomy
Laparoscopic & open splenic removal
Removal of the spleen. Laparoscopic preferred unless spleen >30cm or trauma. Indications: ITP, hemolytic anemia, splenic artery aneurysm, splenic cysts, lymphoma staging, trauma (Grade III–V).
| CPT | Description |
|---|---|
| 38100 | Splenectomy, total, open |
| 38102 | Splenectomy, total, open; with repair for trauma |
| 38120 | Laparoscopic splenectomy |
| 38115 | Repair of ruptured spleen, open (splenorrhaphy) |
D69.3D55.0S36.039AD73.5C83.39
| ICD-10 | Description |
|---|---|
| D69.3 | Immune thrombocytopenic purpura (ITP) |
| S36.039A | Laceration of spleen, unspecified — initial encounter (trauma) |
| D73.5 | Infarction of spleen |
Medical Necessity for ITPPayers require failure of first-line therapy (steroids, IVIG, TPO agonists) documented before approving splenectomy for ITP.
Trauma Setting AuthorizationEmergent trauma splenectomy — authorization not required but facility must submit with proper POS (21 inpatient) and trauma diagnosis codes.
Lysis of Adhesions / Bowel Obstruction
Small bowel obstruction surgical treatment
Division of peritoneal adhesions causing small or large bowel obstruction. Laparoscopic approach preferred for non-complicated SBO; open required for strangulation, ischemia, or extensive adhesions requiring resection.
| CPT | Description |
|---|---|
| 44005 | Enterolysis (freeing of intestinal adhesion) — open |
| 44180 | Laparoscopic enterolysis |
| 44120 | Enterectomy, resection of small intestine, single resection and anastomosis |
| 44125 | Enterectomy, with creation of stoma |
K56.50K56.51K56.52K56.699K56.0
Adhesiolysis Bundled44005/44180 bundled when performed as part of colectomy or other bowel resection; separate billing requires separate, distinct adhesions requiring significant additional time.
Conservative Management RequiredNon-operative management (NGT decompression) required first for incomplete SBO; surgery for failed conservative management must be documented.
Rubber Band Ligation (Hemorrhoid Banding)
Endoscopic non-excisional treatment
Endoscopic placement of rubber band at base of internal hemorrhoid causing ischemic necrosis and sloughing. Most effective office/ASC procedure for Grade I–III internal hemorrhoids. Can treat multiple columns per session.
| CPT | Description |
|---|---|
| 46221 | Hemorrhoidectomy by rubber band ligation(s) |
| 46230 | Excision of external hemorrhoid tags and/or multiple papillae |
✅ 46221 — one CPT code covers all columns banded in a single session. Do NOT bill per band placed.
K64.0K64.1K64.2K64.8
Unbundling Multiple 46221Billing 46221 x3 (per band) instead of once per session; NCCI edit denies multiples — bill once with units of 1.
Esophagectomy
Ivor Lewis, McKeown, Transhiatal approaches
Resection of the esophagus with gastric pull-up or colonic interposition for anastomosis. Performed for esophageal cancer, Barrett's with HGD, esophageal perforation, end-stage achalasia, or caustic injury.
| CPT | Description |
|---|---|
| 43107 | Total or near total esophagectomy; with thoracotomy only |
| 43112 | Total or near total esophagectomy; with thoracotomy and laparotomy (3-field) |
| 43113 | Total or near total esophagectomy; with colon interposition |
| 43117 | Partial esophagectomy, distal; with thoracotomy and separate abdominal incision |
| 43124 | Total or near total esophagectomy without reconstruction (esophagostomy) |
C15.9K22.70K20.90K22.0
Staging Required Pre-AuthOncologic esophagectomy requires pre-op staging workup documentation (CT, PET, EUS) in auth request; denied without imaging evidence.
High Complexity Modifier 22Minimally invasive (MIE) esophagectomy and robotic esophagectomy frequently require modifier 22 and operative note for enhanced reimbursement; otherwise paid at base rate.
Hepatectomy (Liver Resection)
Wedge, segmentectomy, lobectomy
Resection of liver tissue for primary hepatic malignancy (HCC, cholangiocarcinoma), colorectal liver metastases, benign tumors (hemangioma, FNH, adenoma), or living-donor liver transplant.
| CPT | Description |
|---|---|
| 47100 | Biopsy of liver, wedge |
| 47120 | Hepatectomy, resection of liver, partial lobectomy |
| 47122 | Hepatectomy, trisegmentectomy |
| 47125 | Hepatectomy, total left lobectomy |
| 47130 | Hepatectomy, total right lobectomy |
| 47370 | Laparoscopic radiofrequency ablation of liver tumor(s) |
C22.0C78.7D13.4C22.1K76.89
Tumor Board / MDT RequirementMany payers require tumor board documentation before authorizing oncologic hepatectomy for metastatic disease.
Benign Resection Medical NecessityHepatectomy for benign lesions (hemangioma, FNH) denied unless documented symptoms (pain, compression, rupture risk) or diagnostic uncertainty.