Chapter 4 (p. 105) Surgery
DIGESTIVE SYSTEM
Tonsillectomies/Adenoidectomies (T&A)
(42820, 21, 25, 26)
< 12yrs old or => 12 yrs old
Regrowth/residual tissue means another procedure:
Secondary procedure
First time = Primary procedure
Inherently bilateral. If only 1 side done, use reduced
service code modifier -52 (non-anesthesia). Use
this one bcs it is not a discontinued procedure.
42960-72 for control of hemorrhaging.
Oropharyngeal for tonsillectomy
nasopharyngeal for adenoidectomy
Endoscopies (p. 118)
Code only as far as the scope was passed.
Diagnostic codes are encompassed in surgical codes.
Do not codediagnostic if something was
treated/removed.
If access to the small intestine cannot be obtained, it is
not an endoscopy, it becomes a gastroscopy.
EGD: throat to intestine
Common to have multiple codes if more than 1
thing is being done. (biopsy + dilation of stenosis)
CLO TEST: Takes a bit of lining of stomach, sent to
clinical lab area (looking for H. pylori). Looking for
bacteria. No pathology. Classified as biopsy.
(43239) a culture of bacterial growth. Not
fluid/tissue.
Esophagogastroduodenoscopy: (upper gastrointestinal
endoscopy.
Esophageal Dilation
 Endoscopic: dilating balloon (43220) or plastic
dilators over guide wire to stretch esophagus
(43226)
 Manipulation (no scope): Working blind.
Surgeon sprays throat, uses tapered dilating
instrument into esophagus. Hurst and Maloney
(common bougies) used for esophageal dilation
(43450)
Endoscopic Retrograde Cholangiopancreatography
(ERCP) (43260-43278)
Goes into the common bile duct and pancreatic duct to
diagnose conditions of liver, gallbladder, bile ducts,
and pancreas. Uses X-rays: dyes injected into ducts
to be viewed on x-rays.
Bile drains (cystic and pancreatic ducts) into the
common bile duct at ampulla of vater into the
duodenum.
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Study of gallbladder, bile, and pancreatic ducts means
doing EGD, going down to the duodenum and then
back up. Looks for stone, blockage.
Retrograde (backwards) with a scope.
Note: Alert to coder to the radiological supervision and
interpretation codes.
Lower Gastrointestinal System Endoscopies
 Proctosigmoidoscopy (45300-27) uses a rigid or
flexible scope;
 Sigmoidoscopy (45330-45) Flexible scope;
 Colonoscopy (45355-92): Endoscopy must get past
splenic flexure (proximal to) to be a colonoscopy.
Otherwise use modifier + appropriately document.
Extensive colonoscopy might look at junction of
ileum and large intestine.
Indications: abnormal barium enema, lower GI bleed,
iron deficiency anemia of unknown etiology, and
diarhea. Also for follow-up exam after removal of
neoplastic growth.
Determine:
 The approach
o existing colostomy (44388-44397)
o colotomy (45355)
o rectum (45378-45392)
 Was diagnostic endo part of the surgical endo? If
yes, code only the surgical endoscopy
 What was the purpose of the endoscopy?
Incomplete Colonoscopies
M'care/M'caid Pts for Colonoscopy (handout, pg 2):
G0105, G0121 for cancer screening instead of 45378
when no therapeutic procedure conducted.
If colonoscopy cannot get past splenic flexure, the
procedure (G-code) is incomplete... facility coding
must use modifier -73 or -74 (bcs anesthesia is
involved). Physician codes -53. These allow a
follow-up procedure to be done before the annual
limitation period goes by.
If it's not a screening, do the same thing with CPT codes.
Removal of Tumors or Polyps
 Polyps removed by different techniques should be
coded separately.
o hot biopsy forceps
o bipolar cautery
o snare technique
o Laser (ablation not amenable to removal by
above choices).
Chapter 4 (p. 105) Surgery
DIGESTIVE SYSTEM
Biopsy and Lesion Removal
Lesion removal may be performed after a biopsy or
without a biopsy.
Guidelines:
 Biopsy of lesion + excision of the same lesion in
same operative episode, code the excision only

One lesion biopsied and a different lesion excised,
assign a code for the biopsy and a code for the
exicision. Biopsy code gets -59 appended. Use only
one code if “with or without biopsy” in narrative.

Biopsy codes using “with biopsy, single or multiple”
are used only once, regarless of the number of
biopsies taken.
Incision of External Thrombosed Hemorrhoid (46083)
Clot and diseased hemorrhoid plexus are removed in
one piece.
Rubber Band Ligation (46221)
Without incision or excision. Rubber bands at base
ligate and cut off circulation till they slough off.
Destruction of Internal Hemorrhoids by Thermal
Energy (46930)
Cautery, radiofrequency, and infrared coagulation (light
source coagulates the veins above the hemorrhoid,
causing it to shrink and recede.
Suture Ligation (46945-46946)
Ties base of hemorrhoid with suture material.
Documentation must support the number of
columns or groups ligated.
Hemorrhoidectomy (46250-46262)
Excision codes differentiated by internal, external, or
both. Need documentation to indicate number of
columns or groups (single vs. multiple)
Destruction by Cryosurgery (46999)
Use unlisted code.
Hernia Repairs
Coded by
 the type and/or site of the hernia
 the history of the hernia
 the age of the pt
 clinical presentation of the hernia
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Traditional Hernia Repair (49491-49611)
3 types of repairs:
1. Conventional: Physician pushes bulging tissue back
into abd. cavity, stitches it up. 4-6 wk recovery.
2. Use of Mesh (49568)
Mesh is only coded for incisional or ventral hernia
repairs. This is an add-on code. Mesh is not coded
on other hernia repairs where it is used.
3. Laparoscopic Hernia Repair (49650-49659)
Commonly used to repair bilateral and recurrent
hernias. Surgical Laparoscopy includes diagnostic
laparoscopy.
Paresophageal Hiatal Hernia Repair (43332-43337)
The stomach pushes through the opening in the
diaphragm.