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.
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