2017 colorectal surgery medicare reimbursement coding · pdf file2017 colorectal surgery...

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2018 COLORECTAL SURGERY MEDICARE REIMBURSEMENT CODING GUIDE Effective January 1, 2018 PHYSICIAN 3 HOSPITAL OUTPATIENT 4 ASC 4 CPT CODE 1 / HCPCS CODE 2 CODE DESCRIPTION MEDICARE NAT’L AVG CF=$35.9996 APC AND APC DESCRIPTION MEDICARE NAT’L AVG MEDICARE NAT’L AVG FACILITY SETTING NON-FACILITY SETTING COLECTOMY 44140 Colectomy, partial; with anastomosis $1,399 NA Inpatient only, not reimbursed for hospital outpatient or ASC 44141 Colectomy, partial; with skin level cecostomy or colostomy $1,905 NA Inpatient only, not reimbursed for hospital outpatient or ASC 44143 Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure) $1,737 NA Inpatient only, not reimbursed for hospital outpatient or ASC 44144 Colectomy, partial; with resection, with colostomy or ileostomy and creation of mucofistula $1,846 NA Inpatient only, not reimbursed for hospital outpatient or ASC 44145 Colectomy, partial; with coloproctostomy (low pelvic anastomosis) $1,729 NA Inpatient only, not reimbursed for hospital outpatient or ASC 44146 Colectomy, partial; with coloproctostomy (low pelvic anastomosis), with colostomy $2,212 NA Inpatient only, not reimbursed for hospital outpatient or ASC 44147 Colectomy, partial; abdominal and transanal approach $2,026 NA Inpatient only, not reimbursed for hospital outpatient or ASC 44150 Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy $1,951 NA Inpatient only, not reimbursed for hospital outpatient or ASC 44151 Colectomy, total, abdominal, without proctectomy; with continent ileostomy $2,255 NA Inpatient only, not reimbursed for hospital outpatient or ASC 44155 Colectomy, total, abdominal, with proctectomy; with ileostomy $2,172 NA Inpatient only, not reimbursed for hospital outpatient or ASC 44156 Colectomy, total, abdominal, with proctectomy; with continent ileostomy $2,416 NA Inpatient only, not reimbursed for hospital outpatient or ASC 44157 Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, when performed $2,289 NA Inpatient only, not reimbursed for hospital outpatient or ASC Medicare National Average Rates and Allowables (Not Adjusted for Geography)

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Page 1: 2017 COLORECTAL SURGERY MEDICARE REIMBURSEMENT CODING · PDF file2017 COLORECTAL SURGERY MEDICARE REIMBURSEMENT CODING GUIDE Effective January 1, 2017 ... cecostomy or colostomy $1,900

2018 COLORECTAL SURGERY MEDICARE REIMBURSEMENT CODING GUIDEEffective January 1, 2018

PHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4

CPT CODE1/HCPCSCODE2

CODE DESCRIPTION

MEDICARE NAT’L AVGCF=$35.9996 APC AND APC

DESCRIPTIONMEDICARE NAT’L AVG

MEDICARE NAT’L AVGFACILITY

SETTINGNON-FACILITY

SETTING

COLECTOMY

44140 Colectomy, partial; with anastomosis $1,399 NAInpatient only, not reimbursed for hospital outpatient or ASC

44141Colectomy, partial; with skin level cecostomy or colostomy

$1,905 NAInpatient only, not reimbursed for hospital outpatient or ASC

44143Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure)

$1,737 NAInpatient only, not reimbursed for hospital outpatient or ASC

44144Colectomy, partial; with resection, with colostomy or ileostomy and creation of mucofistula

$1,846 NAInpatient only, not reimbursed for hospital outpatient or ASC

44145Colectomy, partial; with coloproctostomy (low pelvic anastomosis)

$1,729 NAInpatient only, not reimbursed for hospital outpatient or ASC

44146Colectomy, partial; with coloproctostomy (low pelvic anastomosis), with colostomy

$2,212 NAInpatient only, not reimbursed for hospital outpatient or ASC

44147Colectomy, partial; abdominal and transanal approach

$2,026 NAInpatient only, not reimbursed for hospital outpatient or ASC

44150Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy

$1,951 NAInpatient only, not reimbursed for hospital outpatient or ASC

44151Colectomy, total, abdominal, without proctectomy; with continent ileostomy

$2,255 NAInpatient only, not reimbursed for hospital outpatient or ASC

44155Colectomy, total, abdominal, with proctectomy; with ileostomy

$2,172 NAInpatient only, not reimbursed for hospital outpatient or ASC

44156Colectomy, total, abdominal, with proctectomy; with continent ileostomy

$2,416 NAInpatient only, not reimbursed for hospital outpatient or ASC

44157

Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, when performed

$2,289 NAInpatient only, not reimbursed for hospital outpatient or ASC

Medicare National Average Rates and Allowables(Not Adjusted for Geography)

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PHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4

CPT CODE1/HCPCSCODE2

CODE DESCRIPTION

MEDICARE NAT’L AVGCF=$35.9996 APC AND APC

DESCRIPTIONMEDICARE NAT’L AVG

MEDICARE NAT’L AVGFACILITY

SETTINGNON-FACILITY

SETTING

COLECTOMY CONT’D

44160Colectomy, partial, with removal of terminal ileum with ileocolostomy

$1,295 NAInpatient only, not reimbursed for hospital outpatient or ASC

44204Laparoscopy, surgical; colectomy, partial, with anastomosis

$1,605 NAInpatient only, not reimbursed for hospital outpatient or ASC

44205Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum with ileocolostomy

$1,396 NAInpatient only, not reimbursed for hospital outpatient or ASC

44206Laparoscopy, surgical; colectomy, partial, with end colostomy and closure of distal segment (Hartmann type procedure)

$1,827 NAInpatient only, not reimbursed for hospital outpatient or ASC

44207Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis)

$1,899 NAInpatient only, not reimbursed for hospital outpatient or ASC

44208Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) with colostomy

$2,072 NAInpatient only, not reimbursed for hospital outpatient or ASC

44210Laparoscopy, surgical; colectomy, total, abdominal, without proctectomy, with ileostomy or ileoproctostomy

$1,859 NAInpatient only, not reimbursed for hospital outpatient or ASC

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

$2,233 NAInpatient only, not reimbursed for hospital outpatient or ASC

44212Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, with ileostomy

$2,134 NAInpatient only, not reimbursed for hospital outpatient or ASC

44213

Laparoscopy, surgical, mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure)

$197 NAInpatient only, not reimbursed for hospital outpatient or ASC

COLOSTOMY

44188Laparoscopy, surgical, colostomy or skin level cecostomy

$1,279 NAInpatient only, not reimbursed for hospital outpatient or ASC

44206Laparoscopy, surgical; colectomy, partial, with end colostomy and closure of distal segment (Hartmann type procedure)

$1,827 NAInpatient only, not reimbursed for hospital outpatient or ASC

44208Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) with colostomy

$2,072 NAInpatient only, not reimbursed for hospital outpatient or ASC

44320 Colostomy or skin level cecostomy; $1,253 NAInpatient only, not reimbursed for hospital outpatient or ASC

50810

Ureterosigmoidostomy, with creation of sigmoid bladder and establishment of abdominal or perineal colostomy, including intestine anastomosis

$1,457 NAInpatient only, not reimbursed for hospital outpatient or ASC

57307Closure of rectovaginal fistula; abdominal approach, with concomitant colostomy

$1,057 NAInpatient only, not reimbursed for hospital outpatient or ASC

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PHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4

CPT CODE1/HCPCSCODE2

CODE DESCRIPTION

MEDICARE NAT’L AVGCF=$35.9996 APC AND APC

DESCRIPTIONMEDICARE NAT’L AVG

MEDICARE NAT’L AVGFACILITY

SETTINGNON-FACILITY

SETTING

PARACOLOSTOMY HERNIA REPAIR

44346Revision of colostomy; with repair of paracolostomy hernia (separate procedure)

$1,235 NAInpatient only, not reimbursed for hospital outpatient or ASC

RECTAL AND ANAL PROCEDURES

45110Proctectomy; complete, combined abdominoperineal, with colostomy

$1,926 NAInpatient only, not reimbursed for hospital outpatient or ASC

45111Proctectomy; partial resection of rectum, transabdominal approach

$1,132 NAInpatient only, not reimbursed for hospital outpatient or ASC

45112Proctectomy, combined abdominoperineal, pull-through procedure (eg, colo-anal anastomosis)

$1,952 NAInpatient only, not reimbursed for hospital outpatient or ASC

45113

Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), with or without loop ileostomy

$1,982 NAInpatient only, not reimbursed for hospital outpatient or ASC

45114Proctectomy, partial, with anastomosis; abdominal and transsacral approach

$1,898 NAInpatient only, not reimbursed for hospital outpatient or ASC

45116Proctectomy, partial, with anastomosis; transsacral approach only (Kraske type)

$1,631 NAInpatient only, not reimbursed for hospital outpatient or 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

$1,990 NAInpatient only, not reimbursed for hospital outpatient or ASC

45120

Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with pull-through procedure and anastomosis (eg, Swenson, Duhamel, or Soave type operation)

$1,661 NAInpatient only, not reimbursed for hospital outpatient or ASC

45121

Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with subtotal or total colectomy, with multiple biopsies

$1,815 NAInpatient only, not reimbursed for hospital outpatient or ASC

45123Proctectomy, partial, without anastomosis, perineal approach

$1,171 NAInpatient only, not reimbursed for hospital outpatient or ASC

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

$2,862 NAInpatient only, not reimbursed for hospital outpatient or ASC

45130Excision of rectal procidentia, with anastomosis; perineal approach

$1,136 NAInpatient only, not reimbursed for hospital outpatient or ASC

45135Excision of rectal procidentia, with anastomosis; abdominal and perineal approach

$1,362 NAInpatient only, not reimbursed for hospital outpatient or ASC

45136 Excision of ileoanal reservoir with ileostomy $1,894 NAInpatient only, not reimbursed for hospital outpatient or ASC

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PHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4

CPT CODE1/HCPCSCODE2

CODE DESCRIPTION

MEDICARE NAT’L AVGCF=$35.9996 APC AND APC

DESCRIPTIONMEDICARE NAT’L AVG

MEDICARE NAT’L AVGFACILITY

SETTINGNON-FACILITY

SETTING

RECTAL AND ANAL PROCEDURES CONT’D

45150 Division of stricture of rectum $432 NA5312, Level 3 Lower GI Procedures

$936 $488

45160Excision of rectal tumor by proctotomy, transsacral or transcoccygeal approach

$1,066 NA5313, Level 3 Lower GI Procedures

$2,316 $1,139

45171Excision of rectal tumor, transanal approach; not including muscularis propria (ie, partial thickness)

$627 NA5313, Level 3 Lower GI Procedures

$2,316 $1,139

45172Excision of rectal tumor, transanal approach; including muscularis propria (ie, full thickness)

$847 NA5313, Level 3 Lower GI Procedures

$2,316 $1,139

45190

Destruction of rectal tumor (eg, electrodesiccation, electrosurgery, laser ablation, laser resection, cryosurgery) transanal approach

$724 NA5313, Level 3 Lower GI Procedures

$2,316 $1,139

45395Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy

$2,063 NAInpatient only, not reimbursed for hospital outpatient or ASC

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

$2,247 NAInpatient only, not reimbursed for hospital outpatient or ASC

45400Laparoscopy, surgical; proctopexy (for prolapse)

$1,191 NAInpatient only, not reimbursed for hospital outpatient or ASC

45402Laparoscopy, surgical; proctopexy (for prolapse), with sigmoid resection

$1,585 NAInpatient only, not reimbursed for hospital outpatient or ASC

45540Proctopexy (eg, for prolapse); abdominal approach

$1,012 NAInpatient only, not reimbursed for hospital outpatient or ASC

45541Proctopexy (eg, for prolapse); perineal approach

$981 NA5313, Level 3 Lower GI Procedures

$2,316 $1,139

45550Proctopexy (eg, for prolapse); with sigmoid resection, abdominal approach

$1,522 NAInpatient only, not reimbursed for hospital outpatient or ASC

45562Exploration, repair, and presacral drainage for rectal injury

$1,162 NAInpatient only, not reimbursed for hospital outpatient or ASC

45563Exploration, repair, and presacral drainage for rectal injury; with colostomy

$1,721 NAInpatient only, not reimbursed for hospital outpatient or ASC

45990Anorectal exam, surgical, requiring anesthesia (general, spinal, or epidural), diagnostic

$112 NA5313, Level 3 Lower GI Procedures

$2,316 $1,139

46700Anoplasty, plastic operation for stricture; adult

$682 NA5313, Level 3 Lower GI Procedures

$2,316 $1,139

46705Anoplasty, plastic operation for stricture; infant

$574 NAInpatient only, not reimbursed for hospital outpatient or ASC

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PHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4

CPT CODE1/HCPCSCODE2

CODE DESCRIPTION

MEDICARE NAT’L AVGCF=$35.9996 APC AND APC

DESCRIPTIONMEDICARE NAT’L AVG

MEDICARE NAT’L AVGFACILITY

SETTINGNON-FACILITY

SETTING

RECTAL AND ANAL PROCEDURES CONT’D

46706 Repair of anal fistula with fibrin glue $183 NA5313, Level 3 Lower GI Procedures

$2,316 $1,139

46710Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal), pouch advancement; transperineal approach

$1,153 NAInpatient only, not reimbursed for hospital outpatient or ASC

46712

Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal), pouch advancement; combined transperineal and transabdominal approach

$2,326 NAInpatient only, not reimbursed for hospital outpatient or ASC

HEMORRHOID PROCEDURES

46083Incision of thrombosed hemorrhoid, external

$111 $184

5371, Level 1 Urology and Related Services

$229 $120

46220Excision of single external papilla or tag, anus

$123 $2145312, Level 2 Lower GI Procedures

$936 $488

46221Hemorrhoidectomy, internal, by rubber band ligation(s)

$198 $2785311, Level 1 Lower GI Procedures

$710 $180

46230Excision of multiple external papillae or tags, anus

$180 $2835313, Level 3 Lower GI Procedures

$2,316 $1,139

46250Hemorrhoidectomy, external, 2 or more columns/groups

$328 $4815313, Level 3 Lower GI Procedures

$2,316 $1,139

46255Hemorrhoidectomy, internal and external, single column/group;

$368 $5255313, Level 3 Lower GI Procedures

$2,316 $1,139

46257Hemorrhoidectomy, internal and external, single column/group; with fissurectomy

$442 NA5313, Level 3 Lower GI Procedures

$2,316 $1,139

46258Hemorrhoidectomy, internal and external, single column/group; with fistulectomy, including fissurectomy, when performed

$484 NA5313, Level 3 Lower GI Procedures

$2,316 $1,139

46260Hemorrhoidectomy, internal and external, 2 or more columns/groups

$495 NA5313, Level 3 Lower GI Procedures

$2,316 $1,139

46261Hemorrhoidectomy, internal and external, 2 or more columns/groups; with fissurectomy

$545 NA5313, Level 3 Lower GI Procedures

$2,316 $1,139

46262Hemorrhoidectomy, internal and external, 2 or more columns/groups; with fistulectomy, including fissurectomy, when performed

$575 NA5313, Level 3 Lower GI Procedures

$2,316 $1,139

46320Excision of thrombosed hemorrhoid, external

$115 $1915312, Level 2 Lower GI Procedures

$936 $122

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NOTES:

1. CPT copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

2. Centers for Medicare and Medicaid Services. Healthcare Common Procedure Coding System. http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html.

3. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018 Final Rule; 82 Fed. Reg. 52976; 52976-53371: https://www.gpo.gov/fdsys/pkg/FR-2017-11-15/pdf/2017-23953.pdf. Published November 15, 2017. See also the January 2018 release of the PFS Relative Value File RVU18A at https://www.federalregister.gov/documents/2017/12/14/R1-2017-23932/medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment. Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown.

4. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule: 82 Fed. Reg. 52356; 52356-52637 [ CMS- 1678-FC]: https://www.federalregister.gov/documents/2017/12/14/R1-2017-23932/medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment. Published November 13, 2017. Payment is adjusted by the wage index for each hospital or ASC’s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.

5. HCPCS II S-codes cannot be reported to Medicare. They are used only by non-Medicare payers, which cover and price them according to their own requirements.

PHYSICIAN3 HOSPITAL OUTPATIENT4 ASC4

CPT CODE1/HCPCSCODE2

CODE DESCRIPTION

MEDICARE NAT’L AVGCF=$35.9996 APC AND APC

DESCRIPTIONMEDICARE NAT’L AVG

MEDICARE NAT’L AVGFACILITY

SETTINGNON-FACILITY

SETTING

HEMORRHOID PROCEDURES CONT’D

46930Destruction of internal hemorrhoid(s) by thermal energy (eg, infrared coagulation, cautery, radiofrequency)

$153 $2155311, Level 1 Lower GI Procedures

$936 $148

46945Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group

$234 $3205313, Level 3 Lower GI Procedures

$2,316 $226

46946Hemorrhoidectomy, internal, by ligation other than rubber band; 2 or more hemorrhoid columns/groups

$234 $3255313, Level 3 Lower GI Procedures

$2,316 $1,139

ROBOTIC ASSISTANCE5

S2900Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure)5

N/A

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HOSPITAL INPATIENT PROCEDURE CODING FOR COLORECTAL SURGERY

ICD-10-PCS procedure codes1 are used by hospitals to report surgeries and procedures performed in the inpatient setting.

All ICD-10-PCS codes have seven digits, each digit representing a specific character associated with procedures. Code assignment in ICD-10-PCS is a process of “constructing” the code by selecting values from a code table for each of the seven standard characters. Key characters are discussed below.

CHARACTER DESCRIPTION

3: Root Operation

The two main root operations for removal of tissue are B-Excision and T-Resection. By definition, B-Excision involves removing a portion of the body part and T-Resection involves removing the entire body part.2 For example, removal of a segment of the transverse colon is coded to B-Excision and removal of the entire transverse colon is coded to T-Resection.

Note that physicians may use these terms more variably. It is the coder’s responsibility to determine what the physician’s documentation equates to in terms of ICD-10-PCS definitions. The physician is not expected to document using ICD-10-PCS code descriptions.3

It should also be noted that procedural steps necessary to close an operative site, including end-to-end or side-to-side anastomosis, are not coded separately. For example, in a resection of sigmoid colon with anastomosis of the descending colon to rectum, the anastomosis is considered inherent and is not coded.4

4: Body Part

Each body part of the colorectal anatomy is identified separately, from the cecum to the rectum. This means that some colorectal procedures require more than one code to completely capture the procedure. For example, rectosigmoidectomy requires two codes: one for removal of the sigmoid and one for removal of the rectum.

There are also more comprehensive body parts. For example, F-Large Intestine, Right is used for right-sided hemicolectomy, without assigning separate codes for removal of the components: terminal ileum, cecum, ascending colon and transverse colon.5 Similarly, G-Large Intestine, Left is used for left-sided hemicolectomy, without assigning separate codes for removal of the components: sigmoid colon, descending colon, and transverse colon. Body part E-Large Intestine is used when the entire colon is removed.

5: ApproachDifferent codes are constructed depending on the approach:

0-Open involves an open incision to directly expose the surgical site 4-Percutaneous Endoscopic is used for procedures performed via laparoscopy

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ICD-10-PCS PROCEDURE CODE PROCEDURE CODE DESCRIPTION

COLECTOMY

Creation of colostomy or ileostomy is coded separately.6

> PARTIAL EXCISION OF COLON

0DBE0ZZ Excision of large intestine, open approach

0DBF0ZZ Excision of right large intestine, open approach

0DBG0ZZ Excision of left large intestine, open approach

0DBH0ZZ Excision of cecum, open approach

0DBK0ZZ Excision of ascending colon, open approach

0DBL0ZZ Excision of transverse colon, open approach

0DBM0ZZ Excision of descending colon, open approach

0DBN0ZZ Excision of sigmoid colon, open approach

0DBE4ZZ Excision of large intestine, percutaneous endoscopic approach

0DBF4ZZ Excision of right large intestine, percutaneous endoscopic approach

0DBG4ZZ Excision of left large intestine, percutaneous endoscopic approach

0DBH4ZZ Excision of cecum, percutaneous endoscopic approach

0DBK4ZZ Excision of ascending colon, percutaneous endoscopic approach

0DBL4ZZ Excision of transverse colon, percutaneous endoscopic approach

0DBM4ZZ Excision of descending colon, percutaneous endoscopic approach

0DBN4ZZ Excision of sigmoid colon, percutaneous endoscopic approach

> TOTAL EXCISION OF COLON

0DTE0ZZ Resection of large intestine, open approach

0DTF0ZZ Resection of right large intestine, open approach

0DTG0ZZ Resection of left large intestine, open approach

0DTH0ZZ Resection of cecum, open approach

0DTK0ZZ Resection of ascending colon, open approach

0DTL0ZZ Resection of transverse colon, open approach

0DTM0ZZ Resection of descending colon, open approach

0DTN0ZZ Resection of sigmoid colon, open approach

0DTE4ZZ Resection of large intestine, percutaneous endoscopic approach

0DTF4ZZ Resection of right large intestine, percutaneous endoscopic approach

0DTG4ZZ Resection of left large intestine, percutaneous endoscopic approach

0DTH4ZZ Resection of cecum, percutaneous endoscopic approach

0DTK4ZZ Resection of ascending colon, percutaneous endoscopic approach

0DTL4ZZ Resection of transverse colon, percutaneous endoscopic approach

0DTM4ZZ Resection of descending colon, percutaneous endoscopic approach

0DTN4ZZ Resection of sigmoid colon, percutaneous endoscopic approach

COLOSTOMY AND ILEOSTOMY

Character 3 is the root operation. For creation of an ostomy, the root operation is 1-Bypass, because 1-Bypass is defined as altering the route of a tubular body part.7

Character 7 is the qualifier, which adds further information to the code. The codes for colostomy and ileostomy use Qualifier 4-Cutaneous to show that colon or ileum is being exteriorized by being re-routed to an opening in the skin.8

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ICD-10-PCS PROCEDURE CODE PROCEDURE CODE DESCRIPTION

> COLOSTOMY

0D1K0Z4 Bypass ascending colon to cutaneous, open approach

0D1L0Z4 Bypass transverse colon to cutaneous, open approach

0D1M0Z4 Bypass descending colon to cutaneous, open approach

0D1N0Z4 Bypass sigmoid colon to cutaneous, open approach

0D1K4Z4 Bypass ascending colon to cutaneous, percutaneous endoscopic approach

0D1L4Z4 Bypass transverse colon to cutaneous, percutaneous endoscopic approach

0D1M4Z4 Bypass descending colon to cutaneous, percutaneous endoscopic approach

0D1N4Z4 Bypass sigmoid colon to cutaneous, percutaneous endoscopic approach

> ILEOSTOMY

0D1B0Z4 Bypass ileum to cutaneous, open approach

0D1B4Z4 Bypass ileum to cutaneous, percutaneous endoscopic approach

PARACOLOSTOMY HERNIA REPAIR

0WQFXZ2 Repair abdominal wall, stoma, external approach

RECTAL PROCEDURES

Creation of colostomy or ileostomy is coded separately.6

> PARTIAL EXCISION OF RECTUM

0DBP0ZZ Excision of rectum, open approach

0DBP4ZZ Excision of rectum, percutaneous endoscopic approach

> TOTAL EXCISION OF RECTUM

0DTP0ZZ Resection of rectum, open approach

0DTP4ZZ Resection of rectum, percutaneous endoscopic approach

HEMORRHOID PROCEDURES

For hemorrhoids, the root operation depends on the technique: 5-Destruction is used for fulguration and cautery, B-Excision is used for removal of the hemorrhoidal tissue, and L-Occlusion is used for ligation and banding.

065Y0ZC Destruction of hemorrhoidal plexus, open approach

06BY0ZC Excision of hemorrhoidal plexus, open approach

06LY0CC Occlusion of hemorrhoidal plexus with extraluminal device, open approach

06LY0DC Occlusion of hemorrhoidal plexus with intraluminal device, open approach

06LY0ZC Occlusion of hemorrhoidal plexus, open approach

ROBOTIC ASSISTANCE9

8E0W0CZ Robotic assisted procedure of trunk region, open approach

8E0W4CZ Robotic assisted procedure of trunk region, percutaneous endoscopic approach

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Notes:

1. ICD-10-CM: Department of Health and Human Services, Centers for Medicare & Medicaid Services. International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS). http://www.cms.hhs.gov/Medicare/Coding/ICD10/2018-ICD-10-PCS-and-GEMs.html

2. CMS ICD-10-PCS Reference Manual 2016, p.64. See also ICD-10-PCS Procedure Coding System (ICD-10-PCS) 2016 Tables and Index, ICD-10-PCS Definitions appendix (0 3: Medical and Surgical - Operation), root operations Excision and Resection

3. 2016 ICD-10-PCS Official Guidelines for Coding and Reporting (Procedure), A11

4. 2016 ICD-10-PCS Official Guidelines for Coding and Reporting (Procedure), B3.1b; see also Coding Clinic, 4th Q 2014, p.42

5. Coding Clinic, 3rd Q 2014, p.6-7, and 4th Q 2014, p.42

6. Coding Clinic, 4th Q 2014, p.41-42

7. CMS ICD-10-PCS Reference Manual 2016, p.38-40. See also ICD-10-PCS Procedure Coding System (ICD-10-PCS) 2016 Tables and Index, ICD-10-PCS Definitions appendix (0 3: Medical and Surgical - Operation), root operation Bypass

8. AHIIMA ICD-10-PCS: An Allied Approach 2015, p.284, case study 6.

9. Codes for robotic assistance are assigned separately in addition to the primary procedure code.

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HOSPITAL INPATIENT DRGS FOR COLORECTAL SURGERYDRG Assignment FY2018—effective January 1, 2018

Under Medicare’s MS-DRG methodology for hospital inpatient payment, each inpatient stay is assigned to one of about 750 diagnosis-related groups, based on the ICD-10 codes assigned to the diagnoses and procedures. Each MS-DRG has a relative weight that is then converted to a flat payment amount. Implanted devices are typically included in the flat payment and are not paid separately. Only one MS-DRG is assigned for each inpatient stay, regardless of the number of procedures performed. MS-DRGs shown are those typically assigned to the following scenarios when the patient is admitted specifically for the procedure.

MS-DRG1 MS-DRG TITLE1,2

FY 2018 RELATIVE WEIGHT1

FY 2018 GEOMETRIC MEAN LENGTH OF STAY1

FY 2018 SUBJECT TO

PACT,3

FY 2018 MEDICARE NATIONAL AVERAGE4

COLECTOMY

329 Major Small and Large Bowel Procedures W MCC 4.9133 10.8 Yes $29,610

330 Major Small and Large Bowel Procedures W CC 2.4689 6.3 Yes $14,879

331Major Small and Large Bowel Procedures W/O CC/MCC

1.6758 3.8 Yes $10,099

COLOSTOMY AND ILEOSTOMY

329 Major Small and Large Bowel Procedures W MCC 4.9133 10.8 Yes $29,610

330 Major Small and Large Bowel Procedures W CC 2.4689 6.3 Yes $14,879

331Major Small and Large Bowel Procedures W/O CC/MCC

1.6758 3.8 Yes $10,099

PARACOLOSTOMY HERNIA REPAIR

347 Anal and Stomal Procedures W MCC 2.6296 6.3 No $15,847

348 Anal and Stomal Procedures W CC 1.4123 3.7 No $8,511

349 Anal and Stomal Procedures W/O CC/MCC 1.0148 2.5 No $6,116

RECTAL PROCEDURES

332 Rectal Resection W MCC 3.8214 7.7 Yes $23,029

333 Rectal Resection W CC 1.9925 4.4 Yes $12,008

334 Rectal Resection W/O CC/MCC 1.2969 2.5 Yes $7,816

HEMORRHOID PROCEDURES

347 Anal and Stomal Procedures W MCC 2.6296 6.3 No $15,847

348 Anal and Stomal Procedures W CC 1.4123 3.7 No $8,511

349 Anal and Stomal Procedures W/O CC/MCC 1.0148 2.5 No $6,116

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This information is taken from the materials published by the Centers for Medicare and Medicaid Services and the American Medical Association and may be helpful to providers in staying up to date on coding and billing of services. This information cannot guarantee coverage or reimbursement, and Medtronic makes no other representations as to selecting codes for procedures or compliance with any other billing protocols or prerequisites. As with all claims, providers are responsible for exercising their independent clinical judgment in selecting the codes that most accurately reflect the patient’s condition and procedures performed for a patient. Providers should refer to current, complete, and authoritative publications such as AMA HCPCS Level II, CPT publications or insurer policies for selecting codes based on the care rendered to an individual patient, and may wish to contact individual carriers, fiscal intermediaries, or other third-party payers as needed.

CPT® is a registered trademark of the American Medical Association. This information is for educational purposes only and is not intended to serve as reimbursement advice. It is the responsibility of the provider to select the codes that most accurately reflect the patient’s condition and procedures performed, and to consult with each patient’s health plan for appropriate reporting of each procedure. In all cases, services must be medically necessary, actually performed and appropriately documented.

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Notes:

1. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2018 Rates Final Rule, 82 Fed. Reg. 37990-38589: https://www.gpo.gov/fdsys/pkg/FR-2017-08-14/pdf/2017-16434.pdf. Published August 14, 2017.

2. W MCC in MS-DRG titles refers to secondary diagnosis codes that are designated as major complications or comorbidities. MS-DRGs W MCC have at least one major secondary complication or comorbidity. Similarly, W CC in MS-DRG titles refers to secondary diagnosis codes designated as other (non-major) complications or comorbidities, and MS-DRGs W CC have at least one other (non-major) secondary complication or comorbidity. MS-DRGs W/O CC/MCCs have no secondary diagnoses that are designated as complications or comorbidities, major or otherwise. Note that some secondary diagnoses are only designated as CCs or MCCs when the conditions were present on admission, and do not count as CCs or MCCs when the conditions are acquired in the hospital during the stay.

3. Post-Acute Care Transfer (PACT) status refers to selected DRGs in which payment to the hospital may be reduced when the patient is discharged by being transferred out. The DRGs impacted are those marked “Yes” and the patient must be transferred out before the geometric mean length of stay to certain post-acute care providers, including rehabilitation hospitals, long term care hospitals, skilled nursing facilities, or to home under the care of a home health agency. When these conditions are met, the DRG payment is converted to a per diem and payment is made as double the per diem rate for the first day plus the per diem rate for each remaining day up to the full DRG payment.

4. Payment is based on the average standardized operating amount ($5,461.19) plus the capital standard amount ($453.95). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2018 Rates; Correction, 82 Fed. Reg. 46138 - 46163. Tables 1A-1E. https://www.gpo.gov/fdsys/pkg/FR-2017-10-04/pdf/2017-21325.pdf. Published October 5, 2018. The payment rate shown is the standardized amounts for facilities with a wage index greater than one. The average standard amounts shown also assume facilities receive the full quality update. The payment will also be adjusted by the Wage Index for specific geographic locality. Therefore, payment for a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown.