MP 10.01.08
Laparoscopic, Endoscopic, Thoracoscopic Surgery
Medical Policy
Section
Administrative
Issue
12:2013
Original Policy Date
12:2013
Last Review Status/Date
12:2013
Return to Medical Policy Index
Disclaimer
Our medical policies are designed for informational purposes only and are not an authorization,
or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all
terms and conditions of the coverage. Medical technology is constantly changing, and we
reserve the right to review and update our policies periodically.
Description
As used in this policy, endoscopic surgery is a general term describing a form of minimally
invasive surgery in which access to a body cavity is achieved through several small
percutaneous incisions. The surgery is performed using specialized instrumentation inserted
through the incisions (i.e., trocar sites) and guided by the use of a fiberoptic endoscope that
provides visualization of the body cavity on a video screen. In endoscopic surgery, the surgeon
does not have direct visualization of the surgical field, and thus endoscopic techniques require
specialized skills compared to the corresponding open surgical techniques. Endoscopic surgery
may also refer to the use of a fiberoptic endoscope inserted through a body orifice into a body
cavity such as the gastrointestinal tract, bronchi, uterus, or bladder. These applications of
endoscopic surgery are not addressed by this policy.
While endoscopic surgery is a general term, laparoscopic, thoracoscopic, and arthroscopic
surgery describe endoscopic surgery within the abdomen, thoracic cavity, and joint spaces,
respectively. In most instances, the endoscopic technique attempts to duplicate the same
surgical techniques and principles as the corresponding open techniques, with the only
difference being surgical access. For example, laparoscopic cholecystectomy, performed since
1990, espouses the same surgical principles as open cholecystectomy. The advantages of
endoscopic surgery include shorter hospital stays and more rapid recovery such that the patient
may be able to return to work promptly. Disadvantages include a longer operative time,
particularly if the surgeon is early on the learning curve for these new techniques.
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Some endoscopic approaches entail novel surgical principles, and thus raise issues of safety
and effectiveness apart from the safety and effectiveness of the endoscopic approach itself. For
example, open herniorrhaphy is typically done from an inguinal approach, while laparoscopic
herniorrhaphy involves a unique abdominal approach. In other procedures, the surgical
dissection can be done entirely with endoscopic guidance, but the resulting surgical specimen
may be too large to remove through the small trocar incision. Novel approaches have been
devised to overcome this limitation. For example, in laparoscopic splenectomy or nephrectomy,
the resected specimens are placed into a bag intra-abdominally, morcellated, and then removed
through a small muscle-splitting incision. Similarly, laparoscopic colectomy specimens can be
removed through either a muscle-splitting incision, or transanally for distal specimens. Surgeries
can combine an open and laparoscopic approach; for example laparoscopic-assisted vaginal
hysterectomy may entail a laparoscopic surgical dissection, with removal of the specimen
through a vaginal incision similar to an open vaginal hysterectomy.
In most instances it is assumed that an endoscopic approach is a direct substitution for the
corresponding open approach. However, the decreased morbidity of endoscopic surgeries in
general may broaden the patient selection criteria for certain surgeries. For example, open
gastric fundoplication is typically limited to those patients who have failed medical management
with H-2 blockers and antimotility agents. Now, however, laparoscopic fundoplication may be
considered an alternative to lifelong medical management. Similarly, open plantar fasciotomy is
typically reserved for those symptomatic patients who have failed a prolonged attempt at
conservative management. The decreased morbidity of an endoscopic approach may prompt a
shortened period of conservative management.
Endoscopic, laparoscopic, and thoracoscopic CPT codes for which there are CPT codes for the
corresponding open surgical procedure are summarized below. Not included are those CPT
codes describing endoscopic diagnostic procedures and those describing arthroscopic
procedures, with the exception of endoscopic carpal tunnel release and endoscopic plantar
fasciotomy. The following table correlates the laparoscopic CPT code with the corresponding
open procedure.
Laparoscopic Surgical (i.e., non-diagnostic) CPT Codes
Laparoscopic CPT Codes
CPT Code Corresponding Open Procedure
38120: splenectomy
38100: splenectomy
38129: unlisted laparoscopy procedure, spleen
38570: laparoscopic retroperitoneal lymph node 38780: retroperitoneal transabdominal
sampling
lymphadenectomy
38571: laparoscopic bilateral total pelvic
38770: pelvic lymphadenectomy
lymphadenectomy
38572: laparoscopic bilateral total pelvic
38780: retroperitoneal transabdominal
lymphadenectomy with peri-aortic lymph node lymphadenectomy, extensive, including pelvic,
sampling
aortic, and renal nodes
38589: Unlisted laparoscopy procedure,
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lymphatic system
43280: laparoscopic esophagogastric
fundoplication
43279: laparoscopic esophagomyotomy with
fundoplasty (Heller myotomy)
43289: Unlisted laparoscopy procedure,
esophagus
43651-52: laparoscopic transsection of vagal
nerves, truncal or selective, respectively
43653: laparoscopic gastrostomy, without
construction of gastric tube
43653: laparoscopic gastrostomy, temporary
43659: Unlisted laparoscopy procedure,
stomach
44200: laparoscopic enterolysis
44201: laparoscopic jejunostomy
44202: laparoscopic intestinal resection, with
anastomosis
44203: each additional small intestine resection
44204: laparoscopic colectomy, partial, with
anastomosis
44205: laparoscopic colectomy, partial, with
removal of terminal ileum with ileocolostomy
44206: laparoscopic colectomy, Hartmann-type
procedure
44207: laparoscopic colectomy, low pelvic
anastomosis
44208: laparoscopic colectomy, partial, with
coloproctostomy
44210: laparoscopic colectomy, total
abdominal, without proctectomy
44211: laparoscopic colectomy, total
abdominal, with proctectomy with ileoanal
anastomosis, creation of ileal reservoir, with
loop ileostomy, with or without rectal
mucosectomy
44212: laparoscopic colectomy, total
abdominal, with proctectomy with ileoanal
anastomosis, creation of ileal reservoir, with
43324: esophagogastric fundoplasty
43330: Esophagomyotomy (Heller type);
abdominal approach
43640-43641: truncal or highly selective
vagotomy, respectively
No identical CPT code; 43500 (gastrostomy;
with exploration may be the closest)
43830: gastrostomy, temporary
44005: enterolysis
44310: ileostomy or jejunostomy, non-tube
44140-44121: Colectomy partial, with
anastomosis or colostomy, respectively
44160: Colectomy, partial, with removal of
terminal ileum with ileocolostomy
44143: Colectomy, partial, Hartmann-type
procedure
44145: Colectomy, with low pelvic
anastomosis
44146: Colectomy, partial, with
coloproctostomy
44150: Colectomy, total abdominal, without
proctectomy
44152-44153: Colectomy, total abdominal, with
proctectomy with ileoanal anastomosis,
creation of ileal reservoir, with loop ileostomy,
with or without rectal mucosectomy
44155: Colectomy, total abdominal, with
proctectomy with ileoanal anastomosis,
creation of ileal reservoir, with loop ileostomy,
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loop ileostomy, with or without rectal
with or without rectal mucosectomy
mucosectomy
44238: Unlisted laparoscopy procedure,
intestine (except rectum)
44239 Unlisted laparoscopy procedure, rectum
44950-60: appendectomy, as separate
44970: laparoscopy, surgical, appendectomy
procedure, or for ruptured appendix
44979: Unlisted laparoscopy procedure,
appendix
47380-82: Ablation open, of one or more liver
tumors, radiofrequency or crysurgery,
respectively*
47370-71: laparoscopy, surgical ablation of one
or more liver tumor(s) with radiofrequency or
cryosurgery, respectively*
47382: Ablation, one or more liver tumors,
percutaneous, radiofrequency*
*Radiofrequency and cryosurgical ablation of liver tumors considered investigational, when
performed via an open procedure, laparoscopically or percutaneously. See policy No. 7.01.75.
47500: injection procedure for percutaneous
transhepatic cholangiography
47560-61: laparoscopy, surgical; with guided
transhepatic cholangiography, without or with
biopsy, respectively
74300: cholangiography; intraoperative with
radiological supervision and interpretation
74320: cholangiography, percutaneous,
transhepatic, radiological supervision and
interpretation
47562-64: laparoscopic cholecystectomy; any 47600-47610: cholecystectomy with
method, with cholangiography, or exploration of cholangiography or exploration of the common
the common duct, respectively
bile duct, respectively
47570: laparoscopic cholecystoenterostomy
47720: cholecystoenterostomy
47579: unlisted laparoscopy procedure, biliary
system
49320: laparoscopy, abdomen, peritoneum and 49000: exploratory laparotomy, exploratory
omentum, diagnostic
celiotomy
variety of CPT codes corresponding to biopsy
49321: laparoscopic biopsy of biliary system
or aspiration of specific organs or tissue
various CPT codes describing cysts in various
49322: laparoscopic aspiration of cavity or cyst locations, i.e., pancreas (48510), liver (47010),
ovary (58805)
49323: with drainage of lymphocele to
49062; drainage of extraperitoneal lymphocele
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peritoneal cavity
to
peritoneal cavity, open
49329; Unlisted laparoscopic procedure,
abdomen, peritoneum and omentum
49652: Laparoscopy, surgical, repair, ventral,
umbilical, spigelian or epigastric hernia
(includes mesh insertion, when performed);
reducible (new 2009)
49653: ; incarcerated or strangulated (new
2009)
49654: Laparoscopy, surgical, repair, incisional
hernia (includes mesh insertion, when
performed); reducible (new 2009)
49655: ; incarcerated or strangulated (new
2009)
49656: Laparoscopy, surgical, repair, recurrent
incisional hernia (includes mesh insertion, when
performed); reducible (new 2009)
49657: ; incarcerated or strangulated (new
2009)
49568: Implantation of mesh or other
prosthesis for open incisional or ventral hernia
repair or mesh for closure of debridement for
necrotizing soft tissue infection
49495-49525: CPT codes vary according to
patient age,
49650-51: laparoscopic repair of initial,
recurrent inguinal hernia, respectively
initial, recurrent, or incarcerated hernia
49659: Unlisted laparoscopy procedure,
hernioplasty, herniorrhaphy, herniotomy
50541: laparoscopic ablation of renal cysts
50542: laparoscopic ablation of renal mass
lesion
50543: laparoscopic partial nephrectomy
50544: laparoscopic pyeloplasty
50545: laparoscopic radical nephrectomy
50546: laparoscopic nephrectomy
50547: donor nephrectomy from living donor
50548: laparoscopically assisted
nephroureterectomy
50549: unlisted laparoscopic produce, renal
No exact corresponding open procedure, but
CPT code 50280 (Excision or unroofing of
cysts of kidney)
50220-50240 nephrectomy code range
50240: nephrectomy, partial
50400; pyeloplasty
50230:nephrectomy, radical
50220; nephrectomy
50300; donor nephrectomy
50220; nephrectomy
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50610-50630; ureterolithotomy, various
locations
There is no CPT code that describes open
50947: laparoscopic ureteroneocystostomy with
ureteroneocystostomy specifically in
csytoscopy and ureteral stent placement
conjunction with stent placement
50948: laparoscopic ureteroneocystostomy
50780: ureteroneocystostomy
without cystoscopy and stent placement
50949: Unlisted laparoscopy procedure, ureter
51990: laparoscopic urethral suspension for
51840: anterior vesicourethropexy, or
stress incontinence
urethropexy; simple
51992: laparoscopic sling operation for stress
57288; sling operation for stress incontinence
incontinence
54690: laparoscopic orchiectomy
54520: simple orchiectomy
54692: laparoscopic orchiopexy for intra54640-54650; orchiopexy
abdominal testis
54699: unlisted laparoscopy procedure, testis
55550: laparoscopic ligation of spermatic veins
55530-55535: excision of varicocele
for varicocele
55559: unlisted laparoscopy procedure;
spermatic cord
58545-46: Laparoscopy, surgical, myomectomy, 58140, 58146: Surgical myomectomy,
excision, less than or greater than 250 gm,
abdominal approach, less than or greater than
respectively
250 gm, respectively
58550-52: laparoscopic vaginal hysterectomy
for uterus 250 gm or less with or without
removal of tube and/or ovary (addressed in
policy 7.01.57)
50945: laparoscopy, surgical ureterolithotomy
58260-58262: Vaginal hysterectomy with or
without removal of tube(s) and ovary(s)
58553-53: laparoscopic vaginal hysterectomy
for uterus weighing greater than 250 gm with or
without removal of tube and/or ovary
(addressed in policy 7.01.57)
55866: laparoscopy, surgical prostatectomy,
55840: prostatectomy, retropubic radical
retropubic radical
58578: unlisted laparoscopy procedure, uterus
58740: lysis of adhesion
58660: laparoscopic lysis of adhesion
58661: laparoscopic removal of adnexal
structure (partial or total oophorectomy and/or
salpingectomy)
58940: total or partial oophorectomy
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58700: complete or partial salpingectomy
58662: laparoscopic fulguration or excision of
49200-49201: excision or destruction by any
lesions of the ovary, pelvic viscera, or peritoneal method of intra-abdominal or retroperitoneal
surface by any method
tumors or cysts or endometriomas
58600-58615: ligation or transsection of
58670-71: laparoscopic fulguration of oviducts
fallopian tubes
58673: laparoscopic salpingostomy
58770: salpingostomy
58672: laparoscopic fimbrioplasty
58760: fimbrioplasty
58679: unlisted laparoscopy procedure, oviduct,
ovary
59898: unlisted laparoscopy procedure,
maternity care and delivery
60650: laparoscopic adrenalectomy
60540: adrenalectomy
60659: unlisted laparoscopic procedure,
endocrine system
The following table summarizes CPT codes for endoscopic orthopedic procedures and
thoracoscopic procedures with the CPT code for the corresponding open procedure.
Endoscopic/Thoracoscopic CPT Codes
CPT Code Corresponding Open
Procedure
Endoscopic Orthopedic Procedures
29848: arthroscopic release of carpal tunnel ligament
29893: endoscopic plantar fasciotomy
Thoracoscopic Procedures
32601-32606: Thoracoscopy, diagnostic, with and
without biopsy of a variety of structures
32650: pleurodesis
32651-2: partial or total pleural decortication,
respectively
64721: neuroplasty of median nerve at
carpal tunnel
28008: fasciotomy, foot and/or toe
32035: Thoractomy, limited for biopsy of
lung or pleura
32005: chemical pleurodesis
32320: decortication and parietal
pleurectomy
32150 removal of intrapleural foreign
32653: removal of intrapleural foreign body
body
32654: control of traumatic hemorrhage
32110: control of traumatic hemorrhage
32655: excision-plication of bullae
32141: excision-plication of bullae
32656: parietal pleurectomy
32310: parietal pleurectomy
32657: wedge resection
32500: wedge resection
32658: removal of clot or foreign body from pericardial 33020: pericardiotomy for removal of
sac
clot or foreign body
32659: creation of pericardial window, or partial
33025: creation of pericardial window or
resection of pericardial sac for drainage
partial resection for drainage
33030: subtotal or complete
32660: total pericardiectomy
pericardiectomy
32661: excision of pericardial cyst, tumor, mass
33050: excision of pericardial cyst or
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32662: excision of mediastinal mass
32663: lobectomy, total or segmental
32664: thoracic sympathectomy
32665: esophagomyotomy
tumor
39220: excision of mediastinal tumor
324800-32484: describes lobectomy
procedures
64809: sympathectomy, thoracolumbar
43331: esophagomyotomy; thoracic
approach
Policy
The endoscopic procedures listed above may be considered medically necessary as an
alternative to the corresponding open surgical procedures with the exception of laparoscopic
radiofrequency or cryosurgical ablation of liver tumors. These procedures are considered
separately in policy No. 7.01.75.
Policy Guidelines
A listing of patient selection criteria for each
laparoscopic/thoracoscopic/arthroscopic/endoscopic procedure is beyond the scope of this
policy. However, in general, candidates for such an endoscopic procedure should meet patient
selection criteria for the corresponding open procedure; endoscopic procedures should not be
considered an alternative to appropriate medical management. This may be of particular
concern in laparoscopic fundoplication and endoscopic plantar fasciotomy when proposed
before an adequate trial of medical management.
Benefit Application
Physicians may request an increased level of reimbursement compared to the corresponding
open procedure, based on the increased operating room (OR) time and the additional training
and expertise required to perform endoscopic surgery. However, the increased OR time may be
compensated for by the decreased hospitalization and follow-up period. Each plan should
consider whether to treat reimbursement of endoscopic, laparoscopic, or arthroscopic
procedures differently than the corresponding open procedures.
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Rationale
American Medical Association. Common Procedural Terminology Year 2002
Codes
Number
CPT codes
ICD-9 Procedure
04.43
05.29
07.22–07.30
32.21
32.29
32.3
32.4
33.39
34.3
34.4
34.09
34.51
34.59
34.6
34.92
37.12
37.31
37.33
40.11
40.3
41.43
41.5
42.7
43.19
44.01–44.03
44.66
45.61–45.63
Description
See Description section, above
Release of carpal tunnel
Other sympathectomy and ganglionectomy
Adrenalectomy code range
Plication of emphysematous bleb
Other local excision o r destruction of lesion or
tissue of lung
Segmental resection of lung
Lobectomy of lung
Other surgical collapse of lung
Excision or destruction of lesion or tissue of
mediastinum
Excision or destruction of lesion of chest wall
Other incision of pleura
Decortication of lung
Other excision of pleura
Scarification of pleura
Injection into thoracic cavity
Other local excision or destruction of lesion or
tissue of lung
Pericardiectomy
Excision or destruction of other lesion or tissue
of heart
Biopsy of lymphatic structure
Regional lymph node excision
Partial splenectomy
Total splenectomy
Esophagomyotomy
Temporary gastrostomy
Vagotomy, code range
Other procedures for creation of
esophagogastric sphincteric competence
(includes fundoplication)
Other excision of small intestine, code range
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45.71–45.79
45.8
46.01–46.04
46.31–46.39
47.01
51.23
51.24
51.32
51.51
53.00
53.01
53.10
54.21
54.23
54.24
54.4
54.51
59.03
59.12
62.3
62.41–62.42
63.1
65.13
65.24
65.25
65.31
65.41
65.53
65.54
65.63
65.64
65.76
Partial excision of large intestine, code range
Total intra-abdominal colectomy
Exteriorization of intestine, code range
Enterostomy, code range
Laparoscopic appendectomy
Laparoscopic cholecystectomy
Laparoscopic partial cholecystectomy
Anastomosis of gallbladder to intestine
Exploration of common bile duct
Unilateral repair of inguinal hernia, not
otherwise specified
Unilateral repair of direct inguinal hernia
Bilateral repair of inguinal hernia
Laparoscopy
Biopsy of peritoneum
Closed biopsy of intra-abdominal mass
Excision or destruction of peritoneal tissue
Laparoscopic lysis of peritoneal adhesions
(includes laparoscopic enterolysis)
Laparoscopic lysis of perirenal or periureteral
tissue
Laparoscopic lysis of perivesical adhesions
Unilateral orchiectomy
Removal of testes, code range
Excision of variocele and hydrocele of
spermatic cord
Laparoscopic biopsy of ovary
Laparoscopic wedge resection of ovary
Other laparoscopic local excision or destruction
of ovary (includes partial oophorectomy)
Laparoscopic unilateral oophorectomy
Laparoscopic unilateral salpingooophorectomy
Laparoscopic removal of both ovaries at same
operative episode
Laparoscopic removal of remaining ovary
Laparoscopic removal of both ovaries and
tubes at same operative episode
Laparoscopic removal of remaining ovary and
tube
Laparoscopic salpingo-oophoroplasty
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65.81
66.02
66.21–66.22
66.79
68.15
68.16
68.29
68.51
83.14
87.53
ICD-9 Diagnosis
HCPCS
Type of Service
Place of Service
Laparoscopic lysis of adhesions of ovary and
fallopian tube
Salpingostomy
Bilateral endoscopic ligation and crushing, or
division of fallopian tubes, code range
Other repair of fallopian tubes
Closed biopsy of uterine ligaments
Closed biopsy of uterus
Other excision or destruction of lesion of
uterus
Laparoscopically assisted vaginal hysterectomy
(LAVH)
Fasciotomy
Intraoperative cholangiogram
Refer to policy for corresponding open
procedure
No codes
Surgery
Inpatient
Index
Endoscopic Surgery, General
Laparoscopic Surgery, General
Thoracoscopic Surgery, General
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