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CHAPTER 19

DIGESTIVE SYSTEM

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Digestive System

Divided by anatomic site from mouth to abdomen, peritoneum, and omentum + organs that aid digestive process

Many bundled procedures

Surgical procedures for open and endoscopic:

Mouth and related structures

Pharynx

Adenoids

Tonsils

Esophagus

Stomach

Intestines

Appendix

Colon, rectum, and anus

Liver

Biliary tract

Pancreas

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The Digestive System subsection includes codes 40490-49999.

On what basis are the digestive system codes divided? (According to anatomical site beginning with the lips and ending with the abdomen, peritoneum, and omentum)

What are some of the organs that aid the digestive process and are included in this subsection? (Organs such as the pancreas, liver, and gallbladder)

What else is included in this subsection? (Abdomen, peritoneum, omentum, and hernias)

Lips (40490-40799)

Vermilionectomy (40500) is shaving of lip

Vermilion border: Area between lip and mucosal surface of mouth

Large defects (40510-40527)

Repaired with procedures such as transverse wedge excision (40510)

Cheiloplasty is lip repair

Full thickness repair (40650-40654)

Cleft lip repair (40700-40761)

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This is the first subheading of the Digestive Subsection.

Name a reason why a vermilionectomy with repair would need to be performed. (A patient with cancer of the lip)

What is a cleft lip? (A congenital defect when the muscle and tissue of the lip didn’t close properly)

Tongue and Floor of Mouth (41000-41599)

Incision and drainage codes based on:

Sublingual (under tongue)

Submandibular (under mandible)

Masticator space (floor of mouth to hyoid bone)

Extraoral (outside mouth) I&D of abscess, cyst, hematoma on floor of mouth

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Incision and drainages are based on the location of the abscess, cyst, or hematoma.

What other categories fall under the Tongue and Floor of Mouth subheading? (Excision, repair, and other procedures)

Dentoalveolar Structures and Palate/Uvula

Dentoalveolar structures (41800-41899)

Bone (osseous) and soft structures of mouth

Anchors teeth

Palate/Uvula (42000-42299)

Palate (roof of mouth)

Uvula (pendulous structure at back of throat)

Alveolar mucosa. (From Liebgott B: The Anatomical Basis of Dentistry, ed 3, St. Louis, 2011, Mosby.)

Figure 19.6

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Dentoalveolar procedures consist of drainage of abscesses or cysts and excisions of lesions.

Palate/Uvula subheading contains codes for incisions, excisions, and repairs.

Grafts are reported separately.

Salivary Gland and Ducts (42300-42699)

Three salivary glands

Parotid

Submandibular

Sublingual

Codes divided initially by gland

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Codes are divided based on the gland the procedure is performed on or the number of glands involved.

Imaging guidance is reported separately.

Pharynx, Adenoids, and Tonsils (42700-42999)

Incision codes 42700-42725 initially divided on approach

Intraoral

External

Figure 19.9, A & B

Tonsillectomy and adenoidectomy

42820-42836

Based on gland removed and age of patient

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Which category are the biopsies found in? (Excision, Destruction)

Incision category is for peritonsillar abscesses.

Esophagus (43020-43499)

Approaches—Incision, Excision

Cervical

Thoracic

Abdominal

Endoscopy

Code esophageal dilation

Know the device or method used

How each device works

Whether dilation was endoscopic or nonendoscopic

Diagnostic endoscopy always included in surgical endoscopy

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The key for billing removal of foreign bodies of the esophagus is the approach.

What approach does code 43100 use? (Cervical)

Esophagoscopy (43180-43233)

Limited to esophagus only

Scope may be advanced into stomach but is short of pylorus

If scope transverses pyloric channel, becomes an EGD (43235-43259, 43210)

If scope passes beyond second portion of duodenum, report Endoscopy, Small Intestine codes 44360-44408

Multiple procedures, same day, same provider, add modifier -51

Biopsy on two different sites add modifier -59

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Stomach (43500-43999)

Gastric bypass performed for morbid obesity

Many different types, such as RNY

May be performed via laparoscope

Bariatric surgery (43770-43775)

Gastric restrictive device (such as band)

Figure 19.12

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Some procedures are performed open, when the stomach is in full view to the physician, and others are done laparoscopically. Be certain to identify the approach used.

The gastric banding is adjustable because the band is a hollow tube that can be inflated and deflated with the administration of fluid.

Intestines (Except Rectum) (44005-44799)

Separate procedures common

Colostomies always bundled with major procedure

Unless code states otherwise

Small intestine extends for 20 feet from pyloric sphincter to first part of large intestine

Large intestine extends from end of ilium to anus, 4 parts (cecum, colon, sigmoid colon, and rectum)

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Be sure to watch for the codes listed as separate procedures.

Endoscopy, Small Intestine (44360-44408)

Diagnostic bundled into surgical endoscopic

Code to furthest extent of procedure

Through stomal report 44380-44408

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Endoscopic codes can be found throughout the Digestive System subsection by anatomical site.

Is diagnostic endoscopy coded separately when surgical endoscopy is performed? (No, surgical endoscopy always includes diagnostic endoscopy.)

Once anatomic site has been determined, what other factor guides code selection? (The surgical procedure)

Endoscopy Terminology (1 of 2)

Notes define specific terminology

Code descriptions are specific regarding:

Technique and depth of scope

Esophagoscopy: Esophagus only

Esophagogastroscopy: Esophagus to past diaphragm

Esophagogastroduodenoscopy: Esophagus to beyond pyloric channel

Read notes preceding 45300-45398

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The notes define the specific terminology that should be used.

In particular, read the notes preceding codes 45300-45398.

Endoscopy Terminology (2 of 2)

Sigmoidoscopy: Entire rectum, sigmoid colon, and may include part of the descending colon (up to 26 inches or 26-60 cm is visualized)

Proctosigmoidoscopy: Rectum and sigmoid colon (6.25 cm is visualized)

Colonoscopy: Entire colon, rectum to cecum, and may include terminal ileum (more than 60 cm visualized or 23.6 inches)

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Understanding the terminology is crucial to coding the procedure appropriately.

What is the route through which the endoscope is inserted during a sigmoidoscopy? (The endoscope is passed through the entire rectum, sigmoid colon, and possibly part of the descending colon.)

Which parts of the anatomy are involved in a colonoscopy? (The entire colon, rectum to cecum, with possible inclusion of the terminal ileum)

Colon Procedures and Screening

For colonoscopy procedures determine how it was performed:

Through a colostomy

Through a colotomy

Through the rectum

For Colorectal Cancer Screening see HCPCS Level II codes:

G0104

G0105

G0106

G0120

G0121

G0122

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Laparoscopy and Endoscopy

Some subheadings have both laparoscopy (from outside) and endoscopy (from inside) procedures

Example: Subheading Esophagus

Endoscopy views inside

Laparoscopy inserted through umbilicus, views from outside

Laparoscopic bariatric surgery codes (43770-43774)

Use of gastric band and/or subcutaneous port components

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Some headings include both laparoscopy (outside) and endoscopy (inside) procedures.

Hemorrhoidectomy and Fistulectomy Codes (46200-46320)

Divided by

Anatomy

Subcutaneous: no muscle involvement

Submuscular: sphincter muscle

Complex fistulectomy involves excision/incision of multiple fistulas

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What is a hemorrhoid? (It is inflammation of the area around the anus)

Hemorrhoids may occur inside or outside of the body.

There are different degrees of severity.

Who should determine the degree of severity? (Physician)

Abdomen, Peritoneum, and Omentum Subheading (49000-49999)

Laparoscopy

Diagnostic (49320)

Surgical (49321-49323)

Repair category contains hernia repair codes

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The Abdomen, Peritoneum, and Omentum subheading includes a repair category that contains hernia repair codes.

Hernia Codes Divided On

Type

Example: inguinal, femoral

Initial or subsequent repair

Age of patient

Clinical presentation:

Strangulated: Blood supply cut off

Incarcerated: Cannot be returned to cavity (not reducible)

Implantation of mesh or prosthesis is reported separately

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Hernia repairs using an abdominal approach are reported with the use of codes 49491-49611.

Hernia repairs performed through laparoscopy are reported by means of codes 49650-49659.

Name some types of hernias. (Inguinal, umbilical, incisional, epigastric, lumbar)

ConclusionCHAPTER 19

DIGESTIVE SYSTEM

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