2015 General Surgery Medicare Reimbursement Coding Guide Effective January 1, 2015 Medicare National Average Rates and Allowables (Not Adjusted For Geography) Physician CPT™* HCPCS Code Procedure Description *MPFS (CF=$35.7547) Fac/Non-Fac AMBULATORY SURGICAL CENTER HOSPITAL OUPATIENT APC Classification APC Descriptor **APC Rate ***ASC ADRENALECTOMY 60540 Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); $1,090.52 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 $1,256.06 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 $1,229.60 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare APPENDECTOMY 44950 Appendectomy; $663.61 0153 Peritoneal and Abdominal Procedures $2,285.91 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) $86.88 NA NA Packaged into Payment for Other Services Not reimbursed in ASC by Medicare 44960 Appendectomy; for ruptured appendix with abscess or generalized peritonitis $903.16 44970 Laparoscopy, surgical, appendectomy $620.34 0131 Level II Laparoscopy $3,779.40 Not reimbursed in ASC by Medicare 44979 Unlisted laparoscopy procedure, appendix Carrier Priced 0130 Level I Laparoscopy $3,016.93 Not reimbursed in ASC by Medicare Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare CHOLECYSTECTOMY 47562 Laparoscopy, surgical; cholecystectomy $679.34 0131 Level II Laparoscopy $3,779.40 $2,070.94 47563 Laparoscopy, surgical; cholecystectomy with cholangiography $737.62 0131 Level II Laparoscopy $3,779.40 $2,070.94 Page 1 of 10 2015 Reimbursement Guide General Surgery Page 2 of 10 Physician CPT™* HCPCS Code Procedure Description AMBULATORY SURGICAL CENTER HOSPITAL OUPATIENT *MPFS (CF=$35.7547) Fac/Non-Fac APC Classification APC Descriptor **APC Rate ***ASC 0131 Level II Laparoscopy $3,779.40 $2,070.94 47564 Laparoscopy, surgical; cholecystectomy with exploration of common duct $1,149.16 47600 Cholecystectomy; $1,103.39 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 47605 Cholecystectomy; with cholangiography $1,160.96 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 47610 Cholecystectomy with exploration of common duct; $1,297.90 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 47612 Cholecystectomy with exploration of common duct; with choledochoenterostomy $1,313.63 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 $1,427.69 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare ESOPHAGECTOMY 43107 Total or near total esophagectomy, without thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty (transhiatal) $2,661.22 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) $4,877.30 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 $2,805.67 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) $4,555.86 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 $5,420.05 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) $2,566.47 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) $3,975.92 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 $2,990.52 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 $2,659.08 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) $4,940.58 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 43124 Total or partial esophagectomy, without reconstruction (any approach), with cervical esophagostomy $3,985.93 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 43620 Gastrectomy, total; with esophagoenterostomy $2,039.09 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 43621 Gastrectomy, total; with Roux-en-Y reconstruction $2,351.59 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 43622 Gastrectomy, total; with formation of intestinal pouch, any type $2,398.43 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 43631 Gastrectomy, partial, distal; with gastroduodenostomy $1,501.34 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare GASTRECTOMY 2015 Reimbursement Guide General Surgery Page 3 of 10 Physician CPT™* HCPCS Code Procedure Description *MPFS (CF=$35.7547) Fac/Non-Fac AMBULATORY SURGICAL CENTER HOSPITAL OUPATIENT APC Classification APC Descriptor **APC Rate ***ASC 43632 Gastrectomy, partial, distal; with gastrojejunostomy $2,103.81 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 43633 Gastrectomy, partial, distal; with Roux-en-Y reconstruction $1,988.32 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 43634 Gastrectomy, partial, distal; with formation of intestinal pouch $2,204.63 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare GASTROESOPHAGEAL REFLUX DISEASE 43235 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) $136.58 / $321.43 0141 Level I Upper GI Procedures $745.60 $408.56 43236 Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance $153.75 / $400.45 0141 Level I Upper GI Procedures $745.60 $408.56 43237 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures $214.53 0419 Level II Upper GI Procedures $1,064.86 $583.50 43238 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures) $255.29 0419 Level II Upper GI Procedures $1,064.86 $583.50 43239 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple $153.39 / $410.46 0141 Level I Upper GI Procedures $745.60 $408.56 43244 Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices $268.88 0419 Level II Upper GI Procedures $1,064.86 $583.50 43245 Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie) $197.72 / $632.50 0419 Level II Upper GI Procedures $1,064.86 $583.50 43246 Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube $218.46 0419 Level II Upper GI Procedures $1,064.86 $583.50 43247 Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s) $194.86 / $418.69 0141 Level I Upper GI Procedures $745.60 $408.56 43248 Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire $183.78 / $422.98 0141 Level I Upper GI Procedures $745.60 $408.56 43249 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) $169.83 / $1,109.47 0419 Level II Upper GI Procedures $1,064.86 $583.50 43279 Laparoscopy, surgical, esophagomyotomy (Heller type), with fundoplasty, when performed $1,340.09 43280 Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures) $1,119.48 43283 Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty) (List separately in addition to code for primary procedure) $165.19 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 43325 Esophagogastric fundoplasty; with fundic patch (Thal-Nissen procedure) $1,393.72 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 43327 Esophagogastric fundoplasty partial or complete; laparotomy $845.60 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 43328 Esophagogastric fundoplasty partial or complete; thoracotomy $1,180.26 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 0132 Level III Laparoscopy $5,479.13 Not reimbursed in ASC by Medicare LAPAROSCOPY 43280 Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures) $1,119.48 0132 Level III Laparoscopy $5,479.13 Not reimbursed in ASC by Medicare 2015 Reimbursement Guide General Surgery Page 4 of 10 Physician CPT™* HCPCS Code Procedure Description *MPFS (CF=$35.7547) Fac/Non-Fac AMBULATORY SURGICAL CENTER HOSPITAL OUPATIENT APC Classification APC Descriptor **APC Rate ***ASC LIVER RESECTION 47120 Hepatectomy, resection of liver; partial lobectomy $2,410.58 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 47122 Hepatectomy, resection of liver; trisegmentectomy $3,353.30 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 47125 Hepatectomy, resection of liver; total left lobectomy $3,180.38 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 47130 Hepatectomy, resection of liver; total right lobectomy $3,417.79 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare LYMPH NODE 0113 Excision Lymphatic System $2,344.50 $1,284.68 $74.01 / $ 129.79 0005 Level II Needle Biopsy/Aspiration Except Bone Marrow $1,052.63 $576.80 Biopsy or excision of lymph node(s); open, deep cervical node(s) $433.70 / $533.46 0113 Excision Lymphatic System $2,344.50 $1,284.68 38520 Biopsy or excision of lymph node(s); open, deep cervical node(s) with excision scalene fat pad $478.40 0113 Excision Lymphatic System $2,344.50 $1,284.68 38550 Excision of cystic hygroma, axillary or cervical; without deep neurovascular dissection $523.81 0113 Excision Lymphatic System $2,344.50 $1,284.68 38555 Excision of cystic hygroma, axillary or cervical; with deep neurovascular dissection $1,039.39 0113 Excision Lymphatic System $2,344.50 $1,284.68 $3,763.00 $2,061.95 38500 Biopsy or excision of lymph node(s); open, superficial $262.44 / $339.31 38505 Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary) 38510 MASTECTOMY 11970 Replacement of tissue expander with permanent prosthesis $622.13 0051 Level III Musculoskeletal Procedures Except Hand and Foot 11971 Removal of tissue expander(s) without insertion of prosthesis $325.01 / $476.61 0022 Level IV Excision/ Biopsy $1,824.31 $999.64 19300 Mastectomy for gynecomastia $422.98 / $533.82 0028 Level I Breast and Skin Surgery $2,167.64 $1,187.77 19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); $670.04 0028 Level I Breast and Skin Surgery $2,167.64 $1,187.77 19302 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy $924.62 0030 Level III Breast and Skin Surgery $4,150.45 $2,274.26 19303 Mastectomy, simple, complete $1,037.96 0029 Level II Breast and Skin Surgery $3,012.77 $1,650.86 19304 Mastectomy, subcutaneous $589.24 0029 Level II Breast and Skin Surgery $3,012.77 $1,650.86 19305 Mastectomy, radical, including pectoral muscles, axillary lymph nodes $1,157.74 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 19306 Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation) $1,231.03 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 19307 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle $1,229.60 0030 Level III Breast and Skin Surgery $4,150.45 Not reimbursed in ASC by Medicare 2015 Reimbursement Guide General Surgery Page 5 of 10 Physician CPT™* HCPCS Code Procedure Description *MPFS (CF=$35.7547) 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 $1,617.19 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 48145 Pancreatectomy, distal subtotal, with or without splenectomy; with pancreaticojejunostomy $1,691.91 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 48146 Pancreatectomy, distal, near-total with preservation of duodenum (Child-type procedure) $1,945.77 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 $3,220.78 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 $2,990.88 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 48153 Pancreatectomy, proximal subtotal with neartotal duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); with pancreatojejunostomy $3,203.62 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 48154 Pancreatectomy, proximal subtotal with neartotal duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); without pancreatojejunostomy $3,004.47 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 48155 Pancreatectomy, total $1,877.12 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 48160 Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells Not Covered by Medicare Not Covered by Medicare ROBOTIC ASSISTANCE S2900‡ Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure) Not Valid for Medicare SPLENECTOMY 38100 Splenectomy; total (separate procedure) $1,193.13 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 38101 Splenectomy; partial (separate procedure) $1,206.36 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) $271.74 Inpatient Procedures, not reimbursed in outpatient or ASC by Medicare 38120 Laparoscopy, surgical, splenectomy $1,088.73 0131 Level II Laparoscopy $3,779.40 Not reimbursed in ASC by Medicare NOTES: • ‡S-Codes are not valid for Medicare payment • 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. • MPFS Facility allowables and ASC rates include patient cost-sharing (coinsurance and deductibles). HOPPS rates include patient cost-sharing (co-payments and deductibles). These amounts are national averages and are not adjusted for geography. • The above 2015 MPFS payment rates reflect policies finalized in the CY 2015 Medicare Physician Fee Schedule Final Rule, CMS-1612-FC that was placed on display at the Federal Register on October 31st, 2014. These rates reflect a zero percent update effective January 1st, 2015 through March 31st, 2015, as provided for by the Protecting Access to Medicare Act of 2014. The CF published in the January update is $35.7547. Current law requires physician fee schedule rates to be reduced by an average of 21.2 percent from the CY 2014 rates because of the existing SGR factor used to calculate the conversion factor. In most prior years, Congress has taken action to avert a large reduction in MPFS rates before they went into effect. Without further congressional action, this updated CF is due to expire on March 31st, 2015. • The above National Average APC and ASC 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. • Rates referenced in this guide do not reflect Sequestration, automatic reductions in federal spending that result in a 2% across-the-board reduction to all Medicare rates. REFERENCES: *PFS Relative Value Files, RVU15B (2-13-15), effective April 1, 2015 **CMS-1613-CN (2-24-15) HOPPS Addendum A and B, effective January 1, 2015 ***CMS-1613-CN (2-24-15) ASC Addendum AA, BB, DD1, DD2, and EE, effective January 1, 2015 ‡CMS 2015 Alpha-Numeric HCPCS File Updated – 11/12/2014 2015 Reimbursement Guide General Surgery Page 6 of 10 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 CHOLECYSTECTOMY 51.21 Other partial cholecystectomy 51.22 Cholecystectomy 51.23 Laparoscopic cholecystectomy 51.24 Laparoscopic partial cholecystectomy 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 43.99 Other total gastrectomy GASTROESOPHAGEAL REFLUX DISEASE 42.01 Incision of esophageal web 42.09 Other incision of esophagus 42.24 Closed [endoscopic] biopsy of esophagus 42.39 Other destruction of lesion or tissue of esophagus 42.92 Dilation of esophagus 42.99 Other operations of esophagus 44.66 Other procedures for creation of esophagogastric sphincteric competence 44.67 Laparoscopic procedures for creation of esophagogastric sphincteric competence LAPAROSCOPY 53.71 Laparoscopic repair of diaphragmatic hernia, abdominal approach LIVER RESECTION 50.22 Partial hepatectomy 50.29 Other destruction of lesion of liver 50.3 Lobectomy of liver 50.4 Total Hepatectomy 50.99 Other operations of Liver LYMPH NODE 40.21 Excision of deep cervical lymph node 40.22 Excision of internal mammary lymph node 40.23 Excision of axillary lymph node 2015 Reimbursement Guide General Surgery Procedure Code* Page 7 of 10 Description 40.24 Excision of inguinal lymph node 40.29 Simple excision of other lymphatic structure 40.40 Radical neck dissection, not otherwise specified 40.41 Radical neck dissection, unilateral 40.42 Radical neck dissection, bilateral 40.50 Radical excision of lymph nodes, not otherwise specified 40.51 Radical excision of axillary lymph nodes 40.52 Radical excision of periaortic lymph nodes 40.53 Radical excision of iliac lymph nodes 40.54 Radical groin dissection 40.59 Radical excision of other lymph nodes MASTECTOMY 85.21 Local excision of lesion of breast 85.22 Resection of quadrant of breast 85.23 Subtotal mastectomy 85.41 Unilateral simple mastectomy 85.42 Bilateral simple mastectomy 85.43 Unilateral extended simple mastectomy 85.44 Bilateral extended simple mastectomy 85.45 Unilateral radical mastectomy 85.46 Bilateral radical mastectomy 85.47 Unilateral extended radical mastectomy 85.48 Bilateral extended radical mastectomy PANCREATECTOMY 52.51 Proximal pancreatectomy 52.52 Distal pancreatectomy 52.53 Radical subtotal pancreatectomy 52.6 Total pancreatectomy 52.7 Radical pancreaticoduodenectomy SPLENECTOMY 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 41.99 Other operations on spleen ROBOTIC ASSISTANCE 17.41 Open robotic assisted procedure 17.42 Laparoscopic robotic assisted procedure 17.43 Percutaneous robotic assisted procedure 17.44 Endoscopic robotic assisted procedure 17.45 Thoracoscopic robotic assisted procedure 17.49 Other and unspecified robotic assisted procedure NOTES: 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. REFERENCES: *2015 Hospital ICD-9-CM Volume 3, 9th Revision, Clinical Modification, Sixth Edition 2015 Reimbursement Guide General Surgery Page 8 of 10 INPATIENT DRG PAYMENT RATES MS-DRG* MS-DRG Title Arithmetic Mean Length of Stay (Days) National Average Payment** ADRENALECTOMY 614 Adrenal and Pituitary Procedures w CC/MCC 5.6 $14,471.80 615 Adrenal and Pituitary Procedures w/o CC/MCC 2.6 $8,364.66 APPENDECTOMY 338 Appendectomy w Complicated Principal Diag w MCC 9.2 $18,030.14 339 Appendectomy w Complicated Principal Diag w CC 5.9 $10,183.47 340 Appendectomy w Complicated Principal Diag w/o CC/MCC 3.5 $7,127.84 341 Appendectomy w/o Complicated Principal Diag w MCC 6.4 $13,426.44 342 Appendectomy w/o Complicated Principal Diag w CC 3.5 $7,700.44 343 Appendectomy w/o Complicated Principal Diag w/o CC/MCC 1.9 $5,522.80 CHOLECYSTECTOMY 411 Cholecystectomy w C.D.E. w MCC 11.7 $21,295.43 412 Cholecystectomy w C.D.E. w CC 7.4 $14,192.26 413 Cholecystectomy w C.D.E. w/o CC/MCC 5.1 $10,399.59 414 Cholecystectomy Except by Laparoscope w/o C.D.E. w MCC 10.6 $20,874.94 415 Cholecystectomy Except by Laparoscope w/o C.D.E. w CC 6.5 $11,902.44 416 Cholecystectomy Except by Laparoscope w/o C.D.E. w/o CC/MCC 4.2 $7,907.75 417 Laparoscopic Cholecystectomy w/o C.D.E. w MCC 7.4 $14,302.08 418 Laparoscopic Cholecystectomy w/o C.D.E. w CC 4.8 $9,748.88 419 Laparoscopic Cholecystectomy w/o C.D.E. w/o CC/MCC 3.0 $7,232.97 ESOPHAGECTOMY 133 Other Ear, Nose, Mouth and Throat O.R. Procedures w CC/MCC 5.4 $10,949.29 134 Other Ear, Nose, Mouth and Throat O.R. Procedures w/o CC/MCC 2.4 $5,921.56 326 Stomach, Esophageal and Duodenal Proc w MCC 14.5 $31,623.37 327 Stomach, Esophageal and Duodenal Proc w CC 7.8 $15,581.77 328 Stomach, Esophageal and Duodenal Proc w/o CC/MCC 3.4 $8,779.28 GASTRECTOMY 326 Stomach, Esophageal and Duodenal Proc w MCC 14.5 $31,623.37 327 Stomach, Esophageal and Duodenal Proc w CC 7.8 $15,581.77 328 Stomach, Esophageal and Duodenal Proc w/o CC/MCC 3.4 $8,779.28 5.4 $10,949.29 GASTROESOPHAGEAL REFLUX DISEASE 133 Other Ear, Nose, Mouth and Throat O.R. Procedures w CC/MCC 134 Other Ear, Nose, Mouth and Throat O.R. Procedures w/o CC/MCC 2.4 $5,921.56 326 Stomach, Esophageal and Duodenal Proc w MCC 14.5 $31,623.37 327 Stomach, Esophageal and Duodenal Proc w CC 7.8 $15,581.77 328 Stomach, Esophageal and Duodenal Proc w/o CC/MCC 3.4 $8,779.28 3.2 $7,353.36 LAPAROSCOPY 355 Hernia Procedures except inguinal and femoral w/o CC/MCC LIVER RESECTION 356 Other Digestive System O.R. Procedures w MCC 11.3 $22,653.23 357 Other Digestive System O.R. Procedures w CC 6.7 $12,375.21 358 Other Digestive System O.R. Procedures w/o CC/MCC 3.9 $8,067.49 405 Pancreas, Liver and Shunt Procedures w MCC 14.4 $32,527.79 406 Pancreas, Liver and Shunt Procedures w CC 7.5 $16,483.24 407 Pancreas, Liver and Shunt Procedures w/o CC/MCC 4.8 $11,435.56 2015 Reimbursement Guide General Surgery MS-DRG* Page 9 of 10 MS-DRG Title Arithmetic Mean Length of Stay (Days) National Average Payment** LYMPH NODE 129 Major Head and Neck Procedures w CC/MCC or Major Device 5.4 $13,674.27 130 Major Head and Neck Procedures w/o CC/MCC 2.8 $7,399.17 133 Other ear, nose, mouth and throat O.R procedure w CC/MCC 5.4 $10,949.29 134 Other ear, nose, mouth and throat O.R procedure w/o CC/MCC 2.4 $5,921.56 163 Major Chest Procedures w MCC 13.2 $29,559.08 164 Major Chest Procedures w CC 6.6 $15,275.20 165 Major Chest Procedures w/o CC/MCC 3.9 $10,700.28 166 Other Resp System O.R. Procedures w MCC 11.1 $21,500.39 167 Other Resp System O.R. Procedures w CC 6.6 $11,638.75 168 Other Resp System O.R. Procedures w/o CC/MCC 3.9 $7,805.57 356 Other Digestive System O.R. Procedures w MCC 11.3 $22,653.23 357 Other Digestive System O.R. Procedures w CC 6.7 $12,375.21 358 Other Digestive System O.R. Procedures w/o CC/MCC 3.9 $8,067.49 MASTECTOMY 582 Mastectomy for Malignancy w CC/MCC 2.9 $7,636.43 583 Mastectomy for Malignancy w/o CC/MCC 1.9 $6,420.17 584 Breast Biopsy, Local Excision and Other Breast Procedures w CC/MCC 5.2 $10,384.32 585 Breast Biopsy, Local Excision and Other Breast Procedures w/o CC/MCC 2.5 $8,076.30 PANCREATECTOMY 405 Pancreas, Liver and Shunt Procedures w MCC 14.4 $32,527.79 406 Pancreas, Liver and Shunt Procedures w CC 7.5 $16,483.24 407 Pancreas, Liver and Shunt Procedures w/o CC/MCC 4.8 $11,435.56 628 Other Endocrine, Nutrit and Metab O.R. Proc w MCC 9.4 $19,342.13 629 Other Endocrine, Nutrit and Metab O.R. Proc w CC 7.5 $13,196.81 630 Other Endocrine, Nutrit and Metab O.R. Proc w/o CC/MCC 4.2 $8,401.07 SPLENECTOMY 799 Splenectomy w MCC 12.2 $29,441.03 800 Splenectomy w CC 7.1 $15,506.01 801 Splenectomy w/o CC/MCC 3.5 $9,089.36 NOTES: *One DRG per patient is assigned to each inpatient stay. REFERENCES: ** FY 2015 Final Rule, Federal Register, Vol. 79, No. 163, Friday, August 22, 2014 and Correction Notice, Federal Register, Vol. 79, No. 192, Friday, October 3, 2014, Table 1A-1E and Table 5. National Average Payment Rate is based upon the National Average Operating Standardized Amount ($5,437.85) plus the Capital Standard Federal Payment Rate ($434.97). 2015 Reimbursement Guide General Surgery Page 10 of 10 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 © 2014 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. ©2015 Covidien. 4.15 US150232 ref# 5974 5920 Longbow Drive 303-530-2300 [t] Boulder, CO 800-255-8522 [us] 80301 www.covidien.com/reimbursement