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CHAPTER 18

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 & endoscopic:

– Mouth & related structures– Pharynx– Adenoids– Tonsils– Esophagus– Stomach– Intestines– Appendix– Rectum and anus– Liver– Biliary tract– Pancreas

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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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Tongue and Floor of Mouth (41000-41599)• Incision and drainage codes based on:

– Sublingual (under tongue)– Submandibular (under mandibular)– 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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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 2, St. Louis, 2001, Mosby, Inc.)

Figure: 18.6

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Salivary Gland and Ducts (42300-42699)• Three salivary glands

– Parotid– Submandibular– Sublingual

• Codes divided initially by gland

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Pharynx, Adenoids, and Tonsils (42700-42999)• Incision codes 42700-42725

initially divided on approach– Intraoral– External

• Tonsillectomy and adenoidectomy– 42820-42836– Based on gland removed and

age of patient

Figure: 18.10, A & B

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Esophagus (43020-43499)• Approaches—Incision, Excision

– Cervical– Thoracic– Abdominal– Endoscopy

• Code esophageal dilation1. Know the device or method used2. How each device works3. Whether dilation was endoscopic or non-endoscopic

• Diagnostic endoscopy always included in surgical endoscopy

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Esophagoscopy (43200-43232)

• Limited to esophagus only• Scope may be advanced into stomach

but is short of pylorus• If scope transverses pyloric channel

becomes an EGD (43234-43259)• If scope passes beyond second portion

of duodenum, becomes an ERCP procedure (43260-43272)

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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: 18.13

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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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Endoscopy, Small Intestine and Stomal (44360-44397)• Diagnostic bundled into surgical

endoscopic• Code to furthest extent of procedure

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Endoscopy Terminology• 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 45300-45392

(Cont’d…)

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Endoscopy Terminology(…Cont’d)

• 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 53 inches)

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Colon Procedures & Screening

• For colonoscopy procedures determine how it was performed:

1. Through a colostomy2. Through a colotomy3. Through the rectum

• For Colorectal Cancer Screening see HCPCS Level II codes:

– G0107– G0104– G0105– G0106– G0120– 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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Hemorrhoidectomy and Fistulectomy Codes (46221-46320)

• Divided by– Anatomy

• Subcutaneous: no muscle involvement• Submuscular: splinter muscle

– Complex fistulectomy involves excision/incision of multiple fistulas

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

• Laparoscopy– Diagnostic (49320)– Surgical (49321-49323)

• Repair category contains hernia repair codes

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Hernia Codes Divided on

1. Type– Example: inguinal, femoral

2. Initial or subsequent repair3. Age of patient4. 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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ConclusionCHAPTER 18

DIGESTIVE SYSTEM