2014 General Surgery
Medicare Reimbursement Coding Guide
Effective January 1, 2014
Medicare National Average Rates and Allowables
(Not Adjusted For Geography)
PHYSICIAN
AMBULATORY
SURGICAL CENTER
HOSPITAL OUPATIENT
Procedure Description
*MPFS
(CF=$35.8228)
Fac/Non-Fac
60540
Adrenalectomy, partial or complete, or exploration of adrenal gland
with or without biopsy, transabdominal, lumbar or dorsal (separate
procedure);
$1,079.70
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
60545
Adrenalectomy, partial or complete, or exploration of adrenal gland
with or without biopsy, transabdominal, lumbar or dorsal (separate
procedure); with excision of adjacent retroperitoneal tumor
$1,242.33
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
60650
Laparoscopy, surgical, with adrenalectomy, partial or complete,
or exploration of adrenal gland with or without biopsy,
transabdominal, lumbar or dorsal
$1,216.54
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
CPT™*
HCPCS
Code
APC
Classification
APC
Descriptor
**APC
Rate
***ASC
ADRENALECTOMY
APPENDECTOMY
44950
Appendectomy;
$654.48
0153
Peritoneal and
Abdominal
Procedures
$1,836.39
Not reimbursed in
ASC by Medicare
+44955
Appendectomy; when done for indicated purpose at time of other
major procedure (not as separate procedure) (List separately in
addition to code for primary procedure)
$85.97
NA
NA
Packaged into
Payment for
Other Services
Not reimbursed in
ASC by Medicare
44960
Appendectomy; for ruptured appendix with abscess or generalized
peritonitis
$891.63
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
BARIATRIC – LAPAROSCOPIC GASTRIC BYPASS
43644
Laparoscopy, surgical, gastric restrictive procedure; with gastric
bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or
less)
$1,768.21
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43645
Laparoscopy, surgical, gastric restrictive procedure; with gastric
bypass and small intestine reconstruction to limit absorption
$1,890.37
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
BARIATRIC – LAPAROSCOPIC GASTRIC BANDING
Carrier Priced
0130
Level I
Laparoscopy
$2,930.99
Not reimbursed in
ASC by Medicare
Laparoscopy, surgical, gastric restrictive procedure; placement
of adjustable gastric restrictive device (eg, gastric band and
subcutaneous port components)
$1,139.17
0132
Level III
Laparoscopy
$5,365.42
Not reimbursed in
ASC by Medicare
Laparoscopy, surgical, gastric restrictive procedure; revision of
adjustable gastric restrictive device component only
$1,302.16
43659
Unlisted laparoscopy procedure, stomach
43770
43771
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
PHYSICIAN
CPT™*
HCPCS
Code
Procedure Description
43772
Laparoscopy, surgical, gastric restrictive procedure; removal of
adjustable gastric restrictive device component only
43773
Laparoscopy, surgical, gastric restrictive procedure; removal and
replacement of adjustable gastric restrictive device component only
43774
Laparoscopy, surgical, gastric restrictive procedure; removal
of adjustable gastric restrictive device and subcutaneous port
components
*MPFS
(CF=$35.8228)
Fac/Non-Fac
AMBULATORY
SURGICAL CENTER
HOSPITAL OUPATIENT
APC
Classification
APC
Descriptor
**APC
Rate
***ASC
$973.31
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
$1,295.71
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
$980.47
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
Carrier Priced
Inpatient Procedure, not reimbursed in outpatient or ASC by Medicare
BARIATRIC – LAPAROSCOPIC SLEEVE GASTRECTOMY
43775
Laparoscopy, surgical, gastric restrictive procedure; longitudinal
gastrectomy (ie, sleeve gastrectomy)
MISCELLANEOUS GASTRIC PROCEDURE (INCLUDING REVISIONS)
43842
Gastric restrictive procedure, without gastric bypass, for morbid
obesity; vertical-banded gastroplasty
$1,182.51
Inpatient Procedure, not reimbursed in outpatient or ASC by Medicare
43843
Gastric restrictive procedure, without gastric bypass, for morbid
obesity; other than vertical-banded gastroplasty
$1,303.95
Inpatient Procedure, not reimbursed in outpatient or ASC by Medicare
43845
Gastric restrictive procedure with partial gastrectomy, pyloruspreserving duodenoileostomy and ileoileostomy (50 to 100 cm
common channel) to limit absorption (biliopancreatic diversion
with duodenal switch)
$1,998.91
Inpatient Procedure, not reimbursed in outpatient or ASC by Medicare
43846
Gastric restrictive procedure, with gastric bypass for morbid obesity;
with short limb (150 cm or less) Roux-en-Y gastroenterostomy
$1,644.98
Inpatient Procedure, not reimbursed in outpatient or ASC by Medicare
43847
Gastric restrictive procedure, with gastric bypass for morbid obesity;
with small intestine reconstruction to limit absorption
$1,836.28
Inpatient Procedure, not reimbursed in outpatient or ASC by Medicare
43848
Revision, open, of gastric restrictive procedure for morbid obesity,
other than adjustable gastric restrictive device (separate procedure)
$1,965.24
Inpatient Procedure, not reimbursed in outpatient or ASC by Medicare
43860
Revision of gastrojejunal anastomosis (gastrojejunostomy) with
reconstruction, with or without partial gastrectomy or intestine
resection; without vagotomy
$1,670.06
Inpatient Procedure, not reimbursed in outpatient or ASC by Medicare
43865
Revision of gastrojejunal anastomosis (gastrojejunostomy) with
reconstruction, with or without partial gastrectomy or intestine
resection; with vagotomy
$1,741.70
Inpatient Procedure, not reimbursed in outpatient or ASC by Medicare
43886
Gastric restrictive procedure, open; revision of subcutaneous port
component only
$369.69
0329
Level IV Skin
Repair
$2,260.46
$1,248.73
43887
Gastric restrictive procedure, open; removal of subcutaneous port
component only
$332.08
0328
Level III Skin
Repair
$1,371.19
$757.47
43888
Gastric restrictive procedure, open; removal and replacement of
subcutaneous port component only
$468.56
0329
Level IV Skin
Repair
$2,260.46
$1,248.73
43999
Unlisted procedure, stomach
Carrier Priced
0141
Level I Upper
GI Procedures
$670.47
Not reimbursed in
ASC by Medicare
74246-26
Radiological examination, gastrointestinal tract, upper, air contrast,
with specific high density barium, effervescent agent, with or
without glucagon; with or without delayed films, without KUB
$35.11
(Professional
Fee)
0277
Level II
Digestive
Radiology
$151.23
$83.54
77002-26
Fluoroscopic guidance for needle placement (eg, biopsy, aspiration,
injection, localization device)
$28.30
(Professional
Fee)
NA
NA
Packaged into
Payment for
Other Services
Packaged Service/
Item
Adjustment of gastric band diameter via subcutaneous port by
injection or aspiration of saline
Carrier Priced
NA
NA
NA
NA
S2083+
CHOLECYSTECTOMY
47562
Laparoscopy, surgical; cholecystectomy
$669.53
0131
Level II
Laparoscopy
$3,648.49
$2,015.50
47563
Laparoscopy, surgical; cholecystectomy with cholangiography
$727.56
0131
Level II
Laparoscopy
$3,648.49
$2,015.50
47564
Laparoscopy, surgical; cholecystectomy with exploration of
common duct
$1,134.51
0131
Level II
Laparoscopy
$3,648.49
$2,015.50
47600
Cholecystectomy;
$1,089.01
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
47605
Cholecystectomy; with cholangiography
$1,145.97
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
47610
Cholecystectomy with exploration of common duct;
$1,278.16
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
PHYSICIAN
CPT™*
HCPCS
Code
Procedure Description
*MPFS
(CF=$35.8228)
Fac/Non-Fac
AMBULATORY
SURGICAL CENTER
HOSPITAL OUPATIENT
APC
Classification
APC
Descriptor
**APC
Rate
***ASC
47612
Cholecystectomy with exploration of common duct; with
choledochoenterostomy
$1,293.92
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
47620
Cholecystectomy with exploration of common duct; with
transduodenal sphincterotomy or sphincteroplasty, with or without
cholangiography
$1,404.97
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
COLECTOMY
44140
Colectomy, partial; with anastomosis
$1,370.58
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44141
Colectomy, partial; with skin level cecostomy or colostomy
$1,867.44
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44143
Colectomy, partial; with end colostomy and closure of distal
segment (Hartmann type procedure)
$1,702.30
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44144
Colectomy, partial; with resection, with colostomy or ileostomy and
creation of mucofistula
$1,811.92
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44145
Colectomy, partial; with coloproctostomy (low pelvic anastomosis)
$1,700.51
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44146
Colectomy, partial; with coloproctostomy (low pelvic anastomosis),
with colostomy
$2,171.94
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44147
Colectomy, partial; abdominal and transanal approach
$1,992.46
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44150
Colectomy, total, abdominal, without proctectomy; with ileostomy
or ileoproctostomy
$1,917.24
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44151
Colectomy, total, abdominal, without proctectomy; with continent
ileostomy
$2,197.01
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44155
Colectomy, total, abdominal, with proctectomy; with ileostomy
$2,139.34
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44156
Colectomy, total, abdominal, with proctectomy; with continent
ileostomy
$2,358.57
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44157
Colectomy, total, abdominal, with proctectomy; with ileoanal
anastomosis, includes loop ileostomy, and rectal mucosectomy,
when performed
$2,231.76
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44158
Colectomy, total, abdominal, with proctectomy; with ileoanal
anastomosis, creation of ileal reservoir (S or J), includes loop
ileostomy, and rectal mucosectomy, when performed
$2,300.54
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44160
Colectomy, partial, with removal of terminal ileum with
ileocolostomy
$1,269.92
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
CYSTECTOMY
51550
Cystectomy, partial; simple
$984.05
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
51555
Cystectomy, partial; complicated (eg, postradiation, previous
surgery, difficult location)
$1,291.41
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
51565
Cystectomy, partial, with reimplantation of ureter(s) into bladder
(ureteroneocystostomy)
$1,314.70
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
51570
Cystectomy, complete; (separate procedure)
$1,503.84
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
51575
Cystectomy, complete; with bilateral pelvic lymphadenectomy,
including external iliac, hypogastric, and obturator nodes
$1,850.61
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
51580
Cystectomy, complete, with ureterosigmoidostomy or
ureterocutaneous transplantations;
$1,927.27
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
51585
Cystectomy, complete, with ureterosigmoidostomy or
ureterocutaneous transplantations; with bilateral pelvic
lymphadenectomy, including external iliac, hypogastric, and
obturator nodes
$2,145.79
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
51590
Cystectomy, complete, with ureteroileal conduit or sigmoid bladder,
including intestine anastomosis;
$1,966.67
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
51595
Cystectomy, complete, with ureteroileal conduit or sigmoid
bladder, including intestine anastomosis; with bilateral pelvic
lymphadenectomy, including external iliac, hypogastric, and
obturator nodes
$2,227.46
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
51596
Cystectomy, complete, with continent diversion, any open
technique, using any segment of small and/or large intestine to
construct neobladder
$2,391.53
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
PHYSICIAN
CPT™*
HCPCS
Code
Procedure Description
*MPFS
(CF=$35.8228)
Fac/Non-Fac
AMBULATORY
SURGICAL CENTER
HOSPITAL OUPATIENT
APC
Classification
APC
Descriptor
**APC
Rate
***ASC
ESOPHAGECTOMY
43107
Total or near total esophagectomy, without thoracotomy; with
pharyngogastrostomy or cervical esophagogastrostomy, with or
without pyloroplasty (transhiatal)
$2,625.45
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43108
Total or near total esophagectomy, without thoracotomy; with
colon interposition or small intestine reconstruction, including
intestine mobilization, preparation and anastomosis(es)
$4,793.45
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43112
Total or near total esophagectomy, with thoracotomy; with
pharyngogastrostomy or cervical esophagogastrostomy, with or
without pyloroplasty
$2,777.70
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43113
Total or near total esophagectomy, with thoracotomy; with colon
interposition or small intestine reconstruction, including intestine
mobilization, preparation, and anastomosis(es)
$4,685.62
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43116
Partial esophagectomy, cervical, with free intestinal graft, including
microvascular anastomosis, obtaining the graft and intestinal
reconstruction
$5,422.14
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43117
Partial esophagectomy, distal two-thirds, with thoracotomy and
separate abdominal incision, with or without proximal gastrectomy;
with thoracic esophagogastrostomy, with or without pyloroplasty
(Ivor Lewis)
$2,548.79
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43118
Partial esophagectomy, distal two-thirds, with thoracotomy and
separate abdominal incision, with or without proximal gastrectomy;
with colon interposition or small intestine reconstruction, including
intestine mobilization, preparation, and anastomosis(es)
$3,727.72
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43121
Partial esophagectomy, distal two-thirds, with thoracotomy
only, with or without proximal gastrectomy, with thoracic
esophagogastrostomy, with or without pyloroplasty
$2,969.35
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43122
Partial esophagectomy, thoracoabdominal or abdominal approach,
with or without proximal gastrectomy; with esophagogastrostomy,
with or without pyloroplasty
$2,637.99
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43123
Partial esophagectomy, thoracoabdominal or abdominal approach,
with or without proximal gastrectomy; with colon interposition
or small intestine reconstruction, including intestine mobilization,
preparation, and anastomosis(es)
$4,856.50
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43124
Total or partial esophagectomy, without reconstruction (any
approach), with cervical esophagostomy
$3,958.06
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
GASTRECTOMY
43620
Gastrectomy, total; with esophagoenterostomy
$2,005.00
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43621
Gastrectomy, total; with Roux-en-Y reconstruction
$2,314.51
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43622
Gastrectomy, total; with formation of intestinal pouch, any type
$2,357.86
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43631
Gastrectomy, partial, distal; with gastroduodenostomy
$1,479.84
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43632
Gastrectomy, partial, distal; with gastrojejunostomy
$2,072.35
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43633
Gastrectomy, partial, distal; with Roux-en-Y reconstruction
$1,958.43
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
43634
Gastrectomy, partial, distal; with formation of intestinal pouch
$2,167.28
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
HEMORRHOID
46083
Incision of thrombosed hemorrhoid, external
$108.90 /
$178.04
0164
Level II Urinary
and Anal
Procedures
$211.10
$116.62
46220
Excision of single external papilla or tag, anus
$122.16 /
$209.56
0155
Level II
Anal/Rectal
Procedures
$1,419.93
$784.40
46221
Hemorrhoidectomy, internal, by rubber band ligation(s)
$195.59 /
$272.25
0148
Level I Anal/
Rectal
Procedures
$472.86
$173.74
46230
Excision of multiple external papillae or tags, anus
$178.04 /
$279.06
0155
Level II
Anal/Rectal
Procedures
$1,419.93
$784.40
46250
Hemorrhoidectomy, external, 2 or more columns/groups
$320.26 /
$466.77
0149
Level III
Anal/Rectal
Procedures
$1,909.22
$1,054.69
PHYSICIAN
CPT™*
HCPCS
Code
Procedure Description
AMBULATORY
SURGICAL CENTER
HOSPITAL OUPATIENT
*MPFS
(CF=$35.8228)
Fac/Non-Fac
APC
Classification
APC
Descriptor
**APC
Rate
***ASC
46255
Hemorrhoidectomy, internal and external, single column/group;
$360.38 /
$510.83
0149
Level III
Anal/Rectal
Procedures
$1,909.22
$1,054.69
46257
Hemorrhoidectomy, internal and external, single column/group;
with fissurectomy
$428.80
0149
Level III
Anal/Rectal
Procedures
$1,909.22
$1,054.69
46258
Hemorrhoidectomy, internal and external, single column/group;
with fistulectomy, including fissurectomy, when performed
$472.86
0149
Level III
Anal/Rectal
Procedures
$1,909.22
$1,054.69
46260
Hemorrhoidectomy, internal and external, 2 or more columns/
groups;
$483.97
0149
Level III
Anal/Rectal
Procedures
$1,909.22
$1,054.69
46261
Hemorrhoidectomy, internal and external, 2 or more columns/
groups; with fissurectomy
$536.63
0149
Level III
Anal/Rectal
Procedures
$1,909.22
$1,054.69
46262
Hemorrhoidectomy, internal and external, 2 or more columns/
groups; with fistulectomy, including fissurectomy, when performed
$564.93
0149
Level III
Anal/Rectal
Procedures
$1,909.22
$1,054.69
44204
Laparoscopy, surgical; colectomy, partial, with anastomosis
$1,579.43
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44205
Laparoscopy, surgical; colectomy, partial, with removal of terminal
ileum with ileocolostomy
$1,374.52
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44206
Laparoscopy, surgical; colectomy, partial, with end colostomy and
closure of distal segment (Hartmann type procedure)
$1,801.53
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44207
Laparoscopy, surgical; colectomy, partial, with anastomosis, with
coloproctostomy (low pelvic anastomosis)
$1,878.55
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44208
Laparoscopy, surgical; colectomy, partial, with anastomosis, with
coloproctostomy (low pelvic anastomosis) with colostomy
$2,044.77
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44210
Laparoscopy, surgical; colectomy, total, abdominal, without
proctectomy, with ileostomy or ileoproctostomy
$1,850.25
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44211
Laparoscopy, surgical; colectomy, total, abdominal, with
proctectomy, with ileoanal anastomosis, creation of ileal reservoir
(S or J), with loop ileostomy, includes rectal mucosectomy, when
performed
$2,304.12
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
44212
Laparoscopy, surgical; colectomy, total, abdominal, with
proctectomy, with ileostomy
$2,130.02
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
LAPAROSCOPIC COLECTOMY
OPEN AND LAPAROSCOPIC NEPHRECTOMY
50220
Nephrectomy, including partial ureterectomy, any open approach
including rib resection;
$1,062.50
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
50225
Nephrectomy, including partial ureterectomy, any open approach
including rib resection; complicated because of previous surgery on
same kidney
$1,219.05
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
50230
Nephrectomy, including partial ureterectomy, any open approach
including rib resection; radical, with regional lymphadenectomy
and/or vena caval thrombectomy
$1,302.52
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
50234
Nephrectomy with total ureterectomy and bladder cuff; through
same incision
$1,322.22
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
50236
Nephrectomy with total ureterectomy and bladder cuff; through
separate incision
$1,489.51
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
50240
Nephrectomy, partial
$1,345.50
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
50543
Laparoscopy, surgical; partial nephrectomy
$1,513.51
50545
Laparoscopy, surgical; radical nephrectomy (includes removal of
Gerota’s fascia and surrounding fatty tissue, removal of regional
lymph nodes, and adrenalectomy)
$1,364.85
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
50546
Laparoscopy, surgical; nephrectomy, including partial ureterectomy
$1,221.92
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
50548
Laparoscopy, surgical; nephrectomy with total ureterectomy
$1,370.22
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
0131
Level II
Laparoscopy
$3,648.49
Not reimbursed in
ASC by Medicare
PHYSICIAN
CPT™*
HCPCS
Code
Procedure Description
*MPFS
(CF=$35.8228)
Fac/Non-Fac
AMBULATORY
SURGICAL CENTER
HOSPITAL OUPATIENT
APC
Classification
APC
Descriptor
**APC
Rate
***ASC
PANCREATECTOMY
48140
Pancreatectomy, distal subtotal, with or without splenectomy;
without pancreaticojejunostomy
$1,593.40
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
48145
Pancreatectomy, distal subtotal, with or without splenectomy; with
pancreaticojejunostomy
$1,663.61
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
48146
Pancreatectomy, distal, near-total with preservation of duodenum
(Child-type procedure)
$1,914.01
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
48150
Pancreatectomy, proximal subtotal with total duodenectomy, partial
gastrectomy, choledochoenterostomy and gastrojejunostomy
(Whipple-type procedure); with pancreatojejunostomy
$3,169.24
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
48152
Pancreatectomy, proximal subtotal with total duodenectomy, partial
gastrectomy, choledochoenterostomy and gastrojejunostomy
(Whipple-type procedure); without pancreatojejunostomy
$2,941.41
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
48153
Pancreatectomy, proximal subtotal with near-total duodenectomy,
choledochoenterostomy and duodenojejunostomy (pylorus-sparing,
Whipple-type procedure); with pancreatojejunostomy
$3,158.14
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
48154
Pancreatectomy, proximal subtotal with near-total duodenectomy,
choledochoenterostomy and duodenojejunostomy (pylorus-sparing,
Whipple-type procedure); without pancreatojejunostomy
$2,953.95
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
48155
Pancreatectomy, total
$1,851.68
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
48160
Pancreatectomy, total or subtotal, with autologous transplantation
of pancreas or pancreatic islet cells
Medicare Non-Covered Service
PROSTATECTOMY
Prostatectomy, perineal, subtotal (including control of
postoperative bleeding, vasectomy, meatotomy, urethral calibration
and/or dilation, and internal urethrotomy)
$1,110.87
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
55810
Prostatectomy, perineal radical;
$1,339.41
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
55812
Prostatectomy, perineal radical; with lymph node biopsy(s) (limited
pelvic lymphadenectomy)
$1,635.67
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
55815
Prostatectomy, perineal radical; with bilateral pelvic
lymphadenectomy, including external iliac, hypogastric and
obturator nodes
$1,792.57
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
55821
Prostatectomy (including control of postoperative bleeding,
vasectomy, meatotomy, urethral calibration and/or dilation, and
internal urethrotomy); suprapubic, subtotal, 1 or 2 stages
$888.05
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
55831
Prostatectomy (including control of postoperative bleeding,
vasectomy, meatotomy, urethral calibration and/or dilation, and
internal urethrotomy); retropubic, subtotal
$960.41
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
55840
Prostatectomy, retropubic radical, with or without nerve sparing;
$1,359.48
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
55842
Prostatectomy, retropubic radical, with or without nerve sparing;
with lymph node biopsy(s) (limited pelvic lymphadenectomy)
$1,456.20
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
55845
Prostatectomy, retropubic radical, with or without nerve sparing;
with bilateral pelvic lymphadenectomy, including external iliac,
hypogastric, and obturator nodes
$1,662.89
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
55866
Laparoscopy, surgical prostatectomy, retropubic radical, including
nerve sparing, includes robotic assistance, when performed
$1,765.35
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45110
Proctectomy; complete, combined abdominoperineal, with
colostomy
$1,904.34
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45111
Proctectomy; partial resection of rectum, transabdominal approach
$1,118.39
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45112
Proctectomy, combined abdominoperineal, pull-through procedure
(eg, colo-anal anastomosis)
$1,941.24
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45113
Proctectomy, partial, with rectal mucosectomy, ileoanal
anastomosis, creation of ileal reservoir (S or J), with or without loop
ileostomy
$2,049.78
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45114
Proctectomy, partial, with anastomosis; abdominal and transsacral
approach
$1,852.04
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45116
Proctectomy, partial, with anastomosis; transsacral approach only
(Kraske type)
$1,612.74
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
55801
RECTAL
PHYSICIAN
CPT™*
HCPCS
Code
Procedure Description
*MPFS
(CF=$35.8228)
Fac/Non-Fac
AMBULATORY
SURGICAL CENTER
HOSPITAL OUPATIENT
APC
Classification
APC
Descriptor
**APC
Rate
***ASC
45119
Proctectomy, combined abdominoperineal pull-through procedure
(eg, colo-anal anastomosis), with creation of colonic reservoir (eg,
J-pouch), with diverting enterostomy when performed
$2,012.17
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45120
Proctectomy, complete (for congenital megacolon), abdominal and
perineal approach; with pull-through procedure and anastomosis
(eg, Swenson, Duhamel, or Soave type operation)
$1,628.50
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45121
Proctectomy, complete (for congenital megacolon), abdominal and
perineal approach; with subtotal or total colectomy, with multiple
biopsies
$1,770.36
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45123
Proctectomy, partial, without anastomosis, perineal approach
$1,153.49
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45126
Pelvic exenteration for colorectal malignancy, with proctectomy
(with or without colostomy), with removal of bladder and ureteral
transplantations, and/or hysterectomy, or cervicectomy, with or
without removal of tube(s), with or without removal of ovary(s), or
any combination thereof
$2,949.65
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45130
Excision of rectal procidentia, with anastomosis; perineal approach
$1,126.63
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45135
Excision of rectal procidentia, with anastomosis; abdominal and
perineal approach
$1,402.10
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45136
Excision of ileoanal reservoir with ileostomy
$1,881.77
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45150
Division of stricture of rectum
45160
Excision of rectal tumor by proctotomy, transsacral or
transcoccygeal approach
45171
$405.16
0149
Level III
Anal/Rectal
Procedures
$1,909.22
$1,054.69
$1,041.01
0149
Level III
Anal/Rectal
Procedures
$1,909.22
$1,054.69
Excision of rectal tumor, transanal approach; not including
muscularis propria (ie, partial thickness)
$615.08
0149
Level III
Anal/Rectal
Procedures
$1,909.22
$1,054.69
45172
Excision of rectal tumor, transanal approach; including muscularis
propria (ie, full thickness)
$835.03
0150
Level IV
Anal/Rectal
Procedures
$2,501.31
$1,381.77
45190
Destruction of rectal tumor (eg, electrodesiccation, electrosurgery,
laser ablation, laser resection, cryosurgery) transanal approach
$713.23
0149
Level III
Anal/Rectal
Procedures
$1,909.22
$1,054.69
45395
Laparoscopy, surgical; proctectomy, complete, combined
abdominoperineal, with colostomy
$2,045.12
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45397
Laparoscopy, surgical; proctectomy, combined abdominoperineal
pull-through procedure (eg, colo-anal anastomosis), with creation
of colonic reservoir (eg, J-pouch), with diverting enterostomy, when
performed
$2,219.22
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45400
Laparoscopy, surgical; proctopexy (for prolapse)
$1,187.53
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45402
Laparoscopy, surgical; proctopexy (for prolapse), with sigmoid
resection
$1,579.07
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45562
Exploration, repair, and presacral drainage for rectal injury;
$1,144.54
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45563
Exploration, repair, and presacral drainage for rectal injury; with
colostomy
$1,676.87
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
45990
Anorectal exam, surgical, requiring anesthesia (general, spinal, or
epidural), diagnostic
$110.33
0155
Level II
Anal/Rectal
Procedures
$1,419.93
$784.40
45999
Unlisted procedure, rectum
Carrier Priced
0148
Level I Anal/
Rectal
Procedures
$472.86
Not reimbursed in
ASC by Medicare
46700
Anoplasty, plastic operation for stricture; adult
$671.32
0149
Level III
Anal/Rectal
Procedures
$1,909.22
$1,054.69
46705
Anoplasty, plastic operation for stricture; infant
$495.07
46706
Repair of anal fistula with fibrin glue
$174.10
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
0149
Level III
Anal/Rectal
Procedures
$1,909.22
$1,054.69
PHYSICIAN
CPT™*
HCPCS
Code
Procedure Description
*MPFS
(CF=$35.8228)
Fac/Non-Fac
AMBULATORY
SURGICAL CENTER
HOSPITAL OUPATIENT
APC
Classification
APC
Descriptor
**APC
Rate
***ASC
46710
Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal),
pouch advancement; transperineal approach
$1,124.84
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
46712
Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal),
pouch advancement; combined transperineal and transabdominal
approach
$2,099.93
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
SPLENECTOMY
38100
Splenectomy; total (separate procedure)
$1,177.14
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
38101
Splenectomy; partial (separate procedure)
$1,186.09
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
+38102
Splenectomy; total, en bloc for extensive disease, in conjunction
with other procedure (List in addition to code for primary
procedure)
$268.31
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
38120
Laparoscopy, surgical, splenectomy
$1,073.97
0131
Level II
Laparoscopy
$3,648.49
Not reimbursed in
ASC by Medicare
THORACIC – DIAGNOSTIC
32096
Thoracotomy, with diagnostic biopsy(ies) of lung infiltrate(s) (eg,
wedge, incisional), unilateral
$835.39
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32097
Thoracotomy, with diagnostic biopsy(ies) of lung nodule(s) or
mass(es) (eg, wedge, incisional), unilateral
$835.75
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32098
Thoracotomy, with biopsy(ies) of pleura
$788.82
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32100
Thoracotomy; with exploration
$844.70
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
0685
Level III
Needle Biopsy/
Aspiration
Except Bone
Marrow
$757.76
$418.60
$757.76
$418.60
Biopsy, pleura; percutaneous needle
$90.63 /
$153.68
32405
Biopsy, lung or mediastinum, percutaneous needle
$107.47 /
$452.08
0685
Level III
Needle Biopsy/
Aspiration
Except Bone
Marrow
32601
Thoracoscopy, diagnostic (separate procedure); lungs, pericardial
sac, mediastinal or pleural space, without biopsy
$320.61
0069
Thoracoscopy
$2,640.12
Not reimbursed in
ASC by Medicare
32604
Thoracoscopy, diagnostic (separate procedure); pericardial sac, with
biopsy
$499.37
0069
Thoracoscopy
$2,640.12
Not reimbursed in
ASC by Medicare
32606
Thoracoscopy, diagnostic (separate procedure); mediastinal space,
with biopsy
$479.67
0069
Thoracoscopy
$2,640.12
Not reimbursed in
ASC by Medicare
32607
Thoracoscopy; with diagnostic biopsy(ies) of lung infiltrate(s) (eg,
wedge, incisional), unilateral
$320.97
0069
Thoracoscopy
$2,640.12
Not reimbursed in
ASC by Medicare
32608
Thoracoscopy; with diagnostic biopsy(ies) of lung nodule(s) or
mass(es) (eg, wedge, incisional), unilateral
$394.05
0069
Thoracoscopy
$2,640.12
Not reimbursed in
ASC by Medicare
32609
Thoracoscopy; with biopsy(ies) of pleura
$271.90
0069
Thoracoscopy
$2,640.12
Not reimbursed in
ASC by Medicare
32110
Thoracotomy; with control of traumatic hemorrhage and/or repair
of lung tear
32400
THORACIC – EXCISION
$1,507.07
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32120
Thoracotomy; for postoperative complications
$902.73
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32140
Thoracotomy; with cyst(s) removal, includes pleural procedure
when performed
$1,027.40
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32141
Thoracotomy; with resection-plication of bullae, includes any
pleural procedure when performed
$1,587.67
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32150
Thoracotomy; with removal of intrapleural foreign body or fibrin
deposit
$1,040.29
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32151
Thoracotomy; with removal of intrapulmonary foreign body
$1,037.07
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32160
Thoracotomy; with cardiac massage
$814.61
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32440
Removal of lung, pneumonectomy;
$1,623.85
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
PHYSICIAN
CPT™*
HCPCS
Code
Procedure Description
*MPFS
(CF=$35.8228)
Fac/Non-Fac
AMBULATORY
SURGICAL CENTER
HOSPITAL OUPATIENT
APC
Classification
APC
Descriptor
**APC
Rate
***ASC
Removal of lung, pneumonectomy; with resection of segment
of trachea followed by broncho-tracheal anastomosis (sleeve
pneumonectomy)
$3,332.95
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32445
Removal of lung, pneumonectomy; extrapleural
$3,667.18
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32480
Removal of lung, other than pneumonectomy; single lobe
(lobectomy)
$1,533.93
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32482
Removal of lung, other than pneumonectomy; 2 lobes
(bilobectomy)
$1,642.83
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32484
Removal of lung, other than pneumonectomy; single segment
(segmentectomy)
$1,488.08
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32486
Removal of lung, other than pneumonectomy; with circumferential
resection of segment of bronchus followed by broncho-bronchial
anastomosis (sleeve lobectomy)
$2,437.38
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32488
Removal of lung, other than pneumonectomy; with all remaining
lung following previous removal of a portion of lung (completion
pneumonectomy)
$2,491.12
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32491
Removal of lung, other than pneumonectomy; with resectionplication of emphysematous lung(s) (bullous or non-bullous) for
lung volume reduction, sternal split or transthoracic approach,
includes any pleural procedure, when performed
$1,524.62
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
+32501
Resection and repair of portion of bronchus (bronchoplasty) when
performed at time of lobectomy or segmentectomy (List separately
in addition to code for primary procedure)
$254.70
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32650
Thoracoscopy, surgical; with pleurodesis (eg, mechanical or
chemical)
$688.87
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32651
Thoracoscopy, surgical; with partial pulmonary decortication
$1,132.36
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32652
Thoracoscopy, surgical; with total pulmonary decortication,
including intrapleural pneumonolysis
$1,720.21
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32653
Thoracoscopy, surgical; with removal of intrapleural foreign body or
fibrin deposit
$1,094.74
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32654
Thoracoscopy, surgical; with control of traumatic hemorrhage
$1,215.83
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32655
Thoracoscopy, surgical; with resection-plication of bullae, includes
any pleural procedure when performed
$989.43
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32656
Thoracoscopy, surgical; with parietal pleurectomy
$826.07
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32658
Thoracoscopy, surgical; with removal of clot or foreign body from
pericardial sac
$739.02
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32659
Thoracoscopy, surgical; with creation of pericardial window or
partial resection of pericardial sac for drainage
$756.94
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32661
Thoracoscopy, surgical; with excision of pericardial cyst, tumor, or
mass
$826.79
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32662
Thoracoscopy, surgical; with excision of mediastinal cyst, tumor, or
mass
$926.02
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32663
Thoracoscopy, surgical; with lobectomy (single lobe)
$1,452.26
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32442
32664
Thoracoscopy, surgical; with thoracic sympathectomy
32665
Thoracoscopy, surgical; with esophagomyotomy (Heller type)
$878.73
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
$1,263.11
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32666
Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass,
nodule), initial unilateral
$901.66
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
+32667
Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass
or nodule), each additional resection, ipsilateral (List separately in
addition to code for primary procedure)
$164.07
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
+32668
Thoracoscopy, surgical; with diagnostic wedge resection followed
by anatomic lung resection (List separately in addition to code for
primary procedure)
$164.07
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
PHYSICIAN
CPT™*
HCPCS
Code
Procedure Description
*MPFS
(CF=$35.8228)
Fac/Non-Fac
AMBULATORY
SURGICAL CENTER
HOSPITAL OUPATIENT
APC
Classification
APC
Descriptor
**APC
Rate
***ASC
THORACIC – HERNIA
32800
Repair lung hernia through chest wall
$976.89
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
THORACIC – PLEURAL
32036
Thoracostomy; with open flap drainage for empyema
$803.86
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32124
Thoracotomy; with open intrapleural pneumonolysis
$961.84
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32200
Pneumonostomy, with open drainage of abscess or cyst
32215
Pleural scarification for repeat pneumothorax
$1,173.91
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
$828.22
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32220
Decortication, pulmonary (separate procedure); total
$1,643.55
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32225
Decortication, pulmonary (separate procedure); partial
$1,030.62
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32310
Pleurectomy, parietal (separate procedure)
32320
Decortication and parietal pleurectomy
$950.74
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
$1,655.01
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32505
Thoracotomy; with therapeutic wedge resection (eg, mass, nodule),
initial
$964.35
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
+32506
Thoracotomy; with therapeutic wedge resection (eg, mass or
nodule), each additional resection, ipsilateral (List separately in
addition to code for primary procedure)
$163.71
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
+32507
Thoracotomy; with diagnostic wedge resection followed by
anatomic lung resection (List separately in addition to code for
primary procedure)
$163.71
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
32540
Extrapleural enucleation of empyema (empyemectomy)
$1,800.10
Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare
49405++
Image-guided fluid collection drainage by catheter (eg, abscess,
hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver,
spleen, lung/mediastinum), percutaneous
$220.31 /
$886.26
0037
Level IV
Needle Biopsy/
Aspiration
Except Bone
Marrow
$1,223.25
Not reimbursed in
ASC by Medicare
NOTES:
+
S-Codes are not valid for Medicare payment
Modifier -26 Professional Component
Multiple Procedure Discounting – Multiple surgical procedures furnished during the same operative session are discounted.
50% is paid for any other surgical procedure(s) performed at the same time.
The above National Average APC and ASC (Freestanding) Rates represent the reimbursement amounts paid directly to the facility for the technical portion of the procedure. The Physician (surgeon) would separately receive the professional
fee (MPFS Allowable) for the procedure performed.
++
CY 2014 CPT Code Manual parenthetical instruction: CPT 32201 (Pneumonostomy; with percutaneous drainage of abscess or cyst) has been deleted CY 2014. For percutaneous image-guided draining of abscess or cyst of lungs or
mediastinum by catheter placement, use CPT 49405 (Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous); new code added
for CY 2014.
TABLE REFERENCES:
*PFS Relative Value File, RVU14A (12-19-13), effective January 1, 2014
**January 2014 HOPPS Addenda A and B (12-19-13), effective January 1, 2014
***January 2014 ASC Addendum AA, BB, DD1, DD2, and EE (1-2-14), effective January 1, 2014
ICD-9-CM Volume 3 Hospital Procedure Codes
Procedure
Code*
Description
ADRENALECTOMY
7.22
Unilateral adrenalectomy
7.29
Other partial adrenalectomy
7.3
Bilateral adrenalectomy
APPENDECTOMY
47.01
Laparoscopic appendectomy
47.09
Other appendectomy
47.11
Laparoscopic incidental appendectomy
47.19
Other incidental appendectomy
43.82
Laparoscopic vertical (sleeve) gastrectomy
43.89
Open and other partial gastrectomy
44.31
High gastric bypass
BARIATRIC
Procedure
Code*
Description
44.38
Laparoscopic gastroenterostomy [Bypass: gastroduodenostomy, gastroenterostomy, gastrogastrostomy. Laproscopic gastrojujenostomy without gastrectomy
NEC]
44.39
Other gastroenterostomy without gastrectomy [Bypass: gastroduodenostomy, gastroenterostomy, gastrogastrostomy. Gastrojujenostomy without
gastrectomy NOS]
44.5
Revision of gastric anastomosis
44.68
Laparoscopic gastroplasty [Banding. Silastic vertical banding. Vertical banded gastroplasty (VBG)]**
44.69
Other repair of stomach
44.95
Laparoscopic gastric restrictive procedure
44.96
Laparoscopic revision of gastric restrictive procedure
44.97
Laparoscopic removal of gastric restrictive device(s)
44.98
(Laparoscopic) adjustment of size of adjustable gastric restrictive device
44.99
Other operations on stomach
45.51
Isolation of segment of small intestine
45.91
Small-to-small intestinal anastomosis
88.1x
Other x-ray of abdomen
51.21
Other partial cholecystectomy
51.22
Cholecystectomy
51.23
Laparoscopic cholecystectomy
51.24
Laparoscopic partial cholecystectomy
45.61
Multiple segmental resection of small intestine
45.62
Other partial resection of small intestine
45.63
Total removal of small intestine
45.71
Open and other multiple segmental resection of large intestine
45.72
Open and other cecectomy
45.73
Open and other right hemicolectomy
45.74
Open and other resection of transverse colon
45.75
Open and other left hemicolectomy
45.76
Open and other sigmoidectomy
45.79
Other and unspecified partial excision of large intestine
45.82
Open total intra-abdominal colectomy
45.83
Other and unspecified total intra-abdominal colectomy
48.61
Transsacral rectosigmoidectomy
48.69
Other resection of rectum
CHOLECYSTECTOMY
COLECTOMY
CYSTECTOMY
57.6
Partial cystectomy
57.71
Radical cystectomy
57.79
Other total cystectomy
ESOPHAGECTOMY
42.40
Esophagectomy, not otherwise specified
42.41
Partial esophagectomy
42.42
Total esophagectomy
GASTRECTOMY
43.5
Partial gastrectomy with anastomosis to esophagus
43.6
Partial gastrectomy with anastomosis to duodenum
43.7
Partial gastrectomy with anastomosis to jejunum
43.81
Partial gastrectomy with jejunal transposition
43.89
Open and other partial gastrectomy
43.91
Total gastrectomy with intestinal interposition
Procedure
Code*
43.99
Description
Other total gastrectomy
HEMORRHOID
49.43
Cauterization of hemorrhoids
49.45
Ligation of hemorrhoids
49.46
Excision of hemorrhoids
49.49
Other procedures on hemorrhoids
LAPAROSCOPIC COLECTOMY
17.31
Laparoscopic multiple segmental resection of large intestine
17.32
Laparoscopic cecectomy
17.33
Laparoscopic right hemicolectomy
17.34
Laparoscopic resection of transverse colon
17.35
Laparoscopic left hemicolectomy
17.36
Laparoscopic sigmoidectomy
17.39
Other laparoscopic partial excision of large intestine
45.81
Laparoscopic total intra-abdominal colectomy
OPEN AND LAPAROSCOPIC NEPHRECTOMY
55.4
Partial nephrectomy
55.51
Nephroureterectomy
55.52
Nephrectomy of remaining kidney
55.54
Bilateral nephrectomy
PANCREATECTOMY
52.51
Proximal pancreatectomy
52.52
Distal pancreatectomy
52.53
Radical subtotal pancreatectomy
52.6
Total pancreatectomy
52.7
Radical pancreaticoduodenectomy
PROSTATECTOMY
60.3
Suprapubic prostatectomy
60.4
Retropubic prostatectomy
60.5
Radical prostatectomy
60.61
Local excision of lesion of prostate
60.62
Perineal prostatectomy
48.50
Abdominoperineal resection of the rectum, not otherwise specified
48.51
Laparoscopic abdominoperineal resection of the rectum
48.52
Open abdominoperineal resection of the rectum
48.59
Other abdominoperineal resection of the rectum
48.61
Transsacral rectosigmoidectomy
48.62
Anterior resection of rectum with synchronous colostomy
48.63
Other anterior resection of rectum
48.64
Posterior resection of rectum
48.69
Other resection of rectum
48.99
Other operations on rectum and perirectal tissue
41.42
Excision of lesion or tissue of spleen
41.43
Partial splenectomy
41.5
Total splenectomy
41.93
Excision of accessory spleen
41.94
Transplantation of spleen
41.95
Repair and plastic operations on spleen
RECTAL
SPLENECTOMY
Procedure
Code*
41.99
Description
Other operations on spleen
THORACIC
32.20
Thoracoscopic excision of lesion or tissue of lung
32.21
Plication of emphysematous bleb
32.22
Lung volume reduction surgery
32.29
Other local excision or destruction of lesion or tissue of lung
32.30
Thoracoscopic segmental resection of lung
32.39
Other and unspecified segmental resection of lung
32.41
Thoracoscopic lobectomy of lung
32.49
Other lobectomy of lung
32.50
Thoracoscopic pneumonectomy
32.59
Other and unspecified pneumonectomy
32.6
Radical dissection of thoracic structures
32.9
Other excision of lung
33.20
Thoracoscopic lung biopsy
33.24
Closed [endoscopic] biopsy of bronchus
33.25
Open biopsy of bronchus
33.26
Closed [percutaneous] [needle] biopsy of lung
33.27
Closed endoscopic biopsy of lung
33.28
Open biopsy of lung
33.29
Other diagnostic procedures on lung or bronchus
34.06
Thoracoscopic drainage of pleural cavity
34.20
Thoracoscopic pleural biopsy
34.21
Transpleural thoracoscopy
34.22
Mediastinoscopy
34.23
Biopsy of chest wall
34.24
Other pleural biopsy
34.25
Closed [percutaneous] [needle] biopsy of mediastinum
34.26
Open mediastinal biopsy
34.27
Biopsy of diaphragm
34.28
Other diagnostic procedures on chest wall, pleura, and diaphragm
34.29
Other diagnostic procedures on mediastinum
34.3
Excision or destruction of lesion or tissue of mediastinum
34.4
Excision or destruction of lesion of chest wall
34.51
Decortication of lung
34.52
Thoracoscopic decortication of lung
34.59
Other excision of pleura
NOTES:
**Code also any synchronous laparoscopic gastroenterostomy (44.38).
The ICD-9-CM Hospital Procedure Codes listed above may be used in the MS-DRG Classifications (See Inpatient DRG Payment Rates Table)
The appropriate MS-DRG classification is also dependent on the diagnosis code, demographics, sex and possible co-conditions.
TABLE REFERENCES:
*
2014 Hospital ICD-9-CM Volume 3, 9th Revision, Clinical Modification, Sixth Edition
Inpatient DRG Payment Rates
Arithmetic Mean Length of Stay
(Days)
National Average
Payment**
Adrenal and Pituitary Procedures w CC/MCC
5.9
$14,762.86
Adrenal and Pituitary Procedures w/o CC/MCC
2.7
$8,455.22
MS-DRG*
MS-DRG Title
ADRENALECTOMY
614
615
APPENDECTOMY
338
Appendectomy w Complicated Principal Diag w MCC
9.5
$18,104.58
339
Appendectomy w Complicated Principal Diag w CC
6.0
$9,927.16
340
Appendectomy w Complicated Principal Diag w/o CC/MCC
3.5
$6,809.30
341
Appendectomy w/o Complicated Principal Diag w MCC
6.3
$12,655.29
342
Appendectomy w/o Complicated Principal Diag w CC
3.5
$7,520.91
343
Appendectomy w/o Complicated Principal Diag w/o CC/MCC
1.9
$5,427.26
BARIATRIC
619
O.R. procedures for obesity w MCC
7.7
$20,994.52
620
O.R. procedures for obesity w CC
3.2
$11,250.62
621
O.R. procedures for obesity w/o CC/MCC
2.0
$9,147.11
987
Non-extensive O.R. procedure unrelated to principal diagnosis w MCC
11.2
$19,383.39
988
Non-extensive O.R. procedure unrelated to principal diagnosis w CC
6.4
$10,180.60
Non-extensive O.R. procedure unrelated to principal diagnosis w/o CC/MCC
3.0
$6,048.97
989
CHOLECYSTECTOMY
411
Cholecystectomy w C.D.E. w MCC
11.3
$20,859.97
412
Cholecystectomy w C.D.E. w CC
7.6
$13,721.25
413
Cholecystectomy w C.D.E. w/o CC/MCC
5.0
$9,986.89
414
Cholecystectomy Except by Laparoscope w/o C.D.E. w MCC
10.6
$20,999.16
415
Cholecystectomy Except by Laparoscope w/o C.D.E. w CC
6.7
$11,699.51
416
Cholecystectomy Except by Laparoscope w/o C.D.E. w/o CC/MCC
4.1
$7,694.90
417
Laparoscopic Cholecystectomy w/o C.D.E. w MCC
7.5
$14,373.70
418
Laparoscopic Cholecystectomy w/o C.D.E. w CC
5.0
$9,590.20
Laparoscopic Cholecystectomy w/o C.D.E. w/o CC/MCC
3.1
$7,098.12
419
COLECTOMY
329
Major Small and Large Bowel Procedures w MCC
14.6
$29,735.66
330
Major Small and Large Bowel Procedures w CC
8.5
$14,852.17
Major Small and Large Bowel Procedures w/o CC/MCC
4.9
$9,499.73
331
CYSTECTOMY
653
Major Bladder Procedures w MCC
15.4
$34,541.20
654
Major Bladder Procedures w CC
8.9
$17,946.25
655
Major Bladder Procedures w/o CC/MCC
5.5
$12,568.29
707
Major Male Pelvic Procedures w CC/MCC
4.1
$10,592.95
708
Major Male Pelvic Procedures w/o CC/MCC
1.6
$7,497.71
749
Other Female Reproductive System O.R. Procedures w CC/MCC
8.4
$15,217.54
Other Female Reproductive System O.R. Procedures w/o CC/MCC
2.8
$6,294.87
750
ESOPHAGECTOMY
133
Other Ear, Nose, Mouth and Throat O.R. Procedures w CC/MCC
5.3
$10,337.19
134
Other Ear, Nose, Mouth and Throat O.R. Procedures w/o CC/MCC
2.4
$5,558.33
326
Stomach, Esophageal and Duodenal Proc w MCC
14.9
$32,485.24
327
Stomach, Esophageal and Duodenal Proc w CC
8.0
$15,425.75
Stomach, Esophageal and Duodenal Proc w/o CC/MCC
3.4
$8,563.09
328
GASTRECTOMY
326
Stomach, Esophageal and Duodenal Proc w MCC
14.9
$32,485.24
327
Stomach, Esophageal and Duodenal Proc w CC
8.0
$15,425.75
328
Stomach, Esophageal and Duodenal Proc w/o CC/MCC
3.4
$8,563.09
MS-DRG*
MS-DRG Title
Arithmetic Mean Length of Stay
(Days)
National Average
Payment**
HEMORRHOID
347
Anal and Stomal Procedures w MCC
8.5
$14,604.53
348
Anal and Stomal Procedures w CC
5.1
$7,878.74
349
Anal and Stomal Procedures w/o CC/MCC
3.0
$5,123.36
LAPAROSCOPIC COLECTOMY
329
Major Small and Large Bowel Procedures w MCC
14.6
$29,735.66
330
Major Small and Large Bowel Procedures w CC
8.5
$14,852.17
331
Major Small and Large Bowel Procedures w/o CC/MCC
4.9
$9,499.73
OPEN AND LAPAROSCOPIC NEPHRECTOMY
656
Kidney and Ureter Procedures for Neoplasm w MCC
9.3
$20,426.74
657
Kidney and Ureter Procedures for Neoplasm w CC
5.4
$11,750.55
658
Kidney and Ureter Procedures for Neoplasm w/o CC/MCC
3.1
$8,742.30
659
Kidney and Ureter Procedures for Non-Neoplasm w MCC
10.3
$19,748.18
660
Kidney and Ureter Procedures for Non-Neoplasm w CC
5.6
$10,918.89
Kidney and Ureter Procedures for Non-Neoplasm w/o CC/MCC
2.8
$7,791.75
661
PANCREATECTOMY
405
Pancreas, Liver and Shunt Procedures w MCC
14.5
$31,510.91
406
Pancreas, Liver and Shunt Procedures w CC
7.6
$16,045.73
407
Pancreas, Liver and Shunt Procedures w/o CC/MCC
5.1
$11,099.84
628
Other Endocrine, Nutrit and Metab O.R. Proc w MCC
9.6
$19,437.33
629
Other Endocrine, Nutrit and Metab O.R. Proc w CC
7.2
$12,348.49
630
Other Endocrine, Nutrit and Metab O.R. Proc w/o CC/MCC
3.8
$7,796.97
PROSTATECTOMY
665
Prostatectomy w MCC
11.7
$18,218.83
666
Prostatectomy w CC
6.2
$9,883.66
667
Prostatectomy w/o CC/MCC
2.6
$5,190.05
707
Major Male Pelvic Procedures w CC/MCC
4.1
$10,592.95
708
Major Male Pelvic Procedures w/o CC/MCC
1.6
$7,497.71
RECTAL
332
Rectal Resection w MCC
13.2
$27,299.83
333
Rectal Resection w CC
7.4
$14,189.28
334
Rectal Resection w/o CC/MCC
4.3
$9,191.77
SPLENECTOMY
799
Splenectomy w MCC
12.9
$29,368.54
800
Splenectomy w CC
6.8
$14,634.69
801
Splenectomy w/o CC/MCC
3.5
$9,267.74
THORACIC
163
Major Chest Procedures w MCC
13.4
$29,550.07
164
Major Chest Procedures w CC
6.7
$15,128.81
165
Major Chest Procedures w/o CC/MCC
4.0
$10,406.20
166
Other Resp System O.R. Procedures w MCC
11.2
$21,308.27
167
Other Resp System O.R. Procedures w CC
6.6
$11,517.99
168
Other Resp System O.R. Procedures w/o CC/MCC
3.9
$7,598.04
820
Lymphoma and Leukemia w Major O.R. Procedure w MCC
17.1
$34,089.41
821
Lymphoma and Leukemia w Major O.R. Procedure w CC
6.9
$13,933.51
822
Lymphoma and Leukemia w Major O.R. Procedure w/o CC/MCC
2.8
$7,154.37
981
Extensive O.R. Procedure Unrelated To Principal Diagnosis w MCC
13.1
$28,603.00
982
Extensive O.R. Procedure Unrelated To Principal Diagnosis w CC
7.6
$16,531.15
983
Extensive O.R. Procedure Unrelated To Principal Diagnosis w/o CC/MCC
3.8
$10,127.24
NOTE:
*
One DRG per patient is assigned to each inpatient stay.
TABLE REFERENCES:
**
FY 2014 Final Rule, Federal Register, Vol. 78, No. 160, Monday, August 19, 2013, Table 1A-1E. National Average Payment Rate is based upon the
National Average Operating Standardized Amount ($5,370.28) plus the Capital Standard Federal Payment Rate ($429.31).
ICD-9-CM Diagnosis Codes
Dx Code**
Description
ADRENALECTOMY
227.0
Benign neoplasm of adrenal gland
255.x*
Disorders of the adrenal glands
APPENDECTOMY
540.0
Acute appendicitis with generalized peritonitis
540.1
Acute appendicitis with peritoneal abscess
540.9
Acute appendicitis without mention of peritonitis
541
Appendicitis, unqualified
789.00
Abdominal pain, unspecified site
278.00
Overweight and obesity
278.01
Morbid obesity
278.02
Overweight
539.01
Infection due to gastric band procedure
539.09
Other complications of gastric band procedure
539.81
Infection due to other bariatric procedure
539.89
Other complication of other bariatric procedure
BARIATRIC
997.49
Other digestive system complication
V12.29
Personal history of other endocrine, metabolic, and immunity disorders
V53.99
Fitting and adjustment, other device
V85
Body Mass Index (BMI), Kilograms per meters squared
V85.0
Body Mass Index less than 19, adult†
V85.1
Body Mass Index between 19-24, adult
V85.2x*
Body Mass Index between 25-29, adult
V85.3x*
Body Mass Index between 30-39, adult
V85.4x*
Body Mass Index 40 and over, adult
V85.5x*
Body Mass Index, pediatric
278.00
Overweight and obesity
CHOLECYSTECTOMY
574.xx*
Cholelithiasis
575.xx*
Other disorders of the gallbladder
153.x*
Malignant neoplasm of the colon
209.13
Malignant carcinoid tumor of the ascending colon
209.14
Malignant carcinoid tumor of the transverse colon
209.15
Malignant carcinoid tumor of the descending colon
209.16
Malignant carcinoid tumor of the sigmoid colon
209.53
Benign carcinoid tumor of the ascending colon
209.54
Benign carcinoid tumor of the transverse colon
209.55
Benign carcinoid tumor of the descending colon
209.56
Benign carcinoid tumor of the sigmoid colon
211.3
Benign neoplasm of colon
230.3
Carcinoma in situ of colon
COLECTOMY
Dx Code**
Description
CYSTECTOMY
188.x*
Malignant neoplasm of the bladder
596.9
Unspecified disorder of the bladder
ESOPHAGECTOMY
150.x*
Malignant neoplasm of esophagus
211.0
Benign neoplasm of esophagus
230.1
Carcinoma in situ of esophagus
530.85
Barrett’s esophagus
GASTRECTOMY
151.x*
Malignant neoplasm of the stomach
531.xx*
Gastric ulcer
532.xx*
Duodenal ulcer
HEMORRHOID
455.x*
Hemorrhoids
569.4x*
Other specified disorders of rectum and anus
LAPAROSCOPIC COLECTOMY
153.x*
Malignant neoplasm of the colon
211.3
Benign neoplasm of colon
235.2
Neoplasm of uncertain behavior of stomach, intestines, and rectum
560.0
Intussusception
560.1
Paralytic ileus
560.30
Impaction of intestine, unspecified
560.9
Unspecified intestinal obstruction
569.82
Ulceration of intestine
569.83
Perforation of intestine
OPEN AND LAPAROSCOPIC NEPHRECTOMY
189.x*
Malignant neoplasm of kidney and other and unspecified urinary organs
209.24
Malignant carcinoid tumor of the kidney
236.91
Neoplasm of uncertain behavior of kidney and ureter
593.x*
Other disorders of kidney and ureter
157.x*
Malignant neoplasm of pancreas
577.x*
Diseases of the pancreas
PANCREATECTOMY
PROSTATECTOMY
185
Malignant neoplasm of prostrate
600.00
Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)
600.01
Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)
600.10
Nodular prostate without urinary obstruction
600.11
Nodular prostate with urinary obstruction
600.20
Benign localized hyperplasia of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS)
600.21
Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS)
600.3
Cyst of prostate
600.90
Hyperplasia of prostate, unspecified, without urinary obstruction and other lower urinary symptoms (LUTS)
600.91
Hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (LUTS)
RECTAL
154.0
Malignant neoplasm of rectosigmoid junction
154.1
Malignant neoplasm of rectum
211.4
Benign neoplasm of rectum and anal canal
235.2
Neoplasm of uncertain behavior of stomach, intestines, and rectum
455.x*
Hemorrhoids
Dx Code**
Description
569.1
Rectal prolapse
569.41
Ulcer of anus and rectum
569.42
Anal or rectal pain
SPLENECTOMY
159.1
Malignant neoplasm of spleen, not elsewhere classified
197.8
Secondary malignant neoplasm of other digestive organs and spleen
200.77
Large cell lymphoma, spleen
289.4
Hypersplenism
289.50
Disease of spleen, unspecified
289.59
Other diseases of spleen
865.xx*
Injury to spleen
THORACIC
162.x*
Malignant neoplasm of trachea, bronchus, and lung
197.0
Secondary malignant neoplasm of lung
235.7
Neoplasm of uncertain behavior of trachea, bronchus, and lung
239.1
Neoplasm of unspecified nature of respiratory system
492.x*
Emphysema
510.x*
Empyema
511.x*
Pleurisy
512.xx*
Pneumothorax and air leak
518.xx*
Other diseases of lung
786.xx*
Symptoms involving respiratory system and other chest symptoms
793.11
Solitary pulmonary nodule
793.19
Other nonspecific abnormal finding of lung field
NOTES:
*
Check 4th or 5th digit.
TABLE REFERENCES:
**
2014 Hospital ICD-9-CM Volume 1 and 2, 9th Revision, Clinical Modification, Sixth Edition
Supply Codes
Dx Code**
Description
BARIATRIC-BAND ADJUSTMENTS
A4208
Syringe with needle, sterile 3 cc, each
A4215
Needle, sterile, any size, each
J7030
Infusion, normal saline solution , 1000 cc
J7040
Infusion, normal saline solution, sterile (500 ml=1 unit)
J7050
Infusion, normal saline solution , 250 cc
REFERENCE:
CMS 2014 Alpha-Numeric HCPCS File Updated – 11/25/2013
Disclaimer:
The information contained in this guide is provided to help you understand the reimbursement process. It is not intended to increase or maximize reimbursement by any
payer. We strongly recommend that providers consult their payer organization with regard to local reimbursement policies. The information contained in this guide is
provided for information purposes only and represents no statement, promise or guarantee by Covidien concerning levels of reimbursement, payment or charge.
Similarly, all CPT HCPCS and ICD-9-CM codes are supplied for information purposes only and represent no statement, promise or guarantee by Covidien that these
codes will be appropriate or that reimbursement will be made. ICD-9-CM is based on the official version of the World Health Organization’s Ninth Revision, International
Classification of Diseases. CPT codes and descriptions only are copyright 2013 American Medical Association. All rights reserved.
CPT does not include fee schedules, relative values or related listings. The source for this information is the Centers for Medicare and Medicaid Services (CMS).
Reimbursement rates reflected in this guide are Medicare National Average rates as published by CMS at the time of printing, and do not reflect provider payment
adjustment factors such geographic adjustment, participation as a Disproportionate Share or Teaching Hospital, participation in the CMS Shared Service (ACO) program,
or Value Base Purchasing adjustments. The content provided by CMS is updated frequently. It is the responsibility of the health services provider to confirm the appropriate
coding required by their local Medicare Administrative Contractors (MACs), carriers, fiscal intermediaries and commercial payers.
All Current Procedural Terminology (CPT) five-digit numeric codes, descriptions, numeric modifiers, instructions, guidelines and other material are copyright © 2013
American Medical Association. All rights reserved.
Code associations and values have been reviewed and validated by NMD Healthcare, Inc.
COVIDIEN, COVIDIEN with logo, Covidien logo and positive results for life are U.S. and internationally
registered trademarks of Covidien AG. ™* Trademark of its respective owner.
©2014 Covidien. 3.14 US140139
5920 Longbow Drive
Boulder, CO
80301
303-530-2300 [t]
800-255-8522 [us]
www.covidien.com/reimbursement