CHAPTER 18 DIGESTIVE SYSTEM

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 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) 2

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) 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) 3

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 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) 4

Dentoalveolar Structures and Palate/Uvula Bone (osseous) and soft structures of mouth Anchors teeth Palate/Uvula (42000-42299) Palate (roof of mouth) Uvula (pendulous structure at back of throat) Figure: 18.6 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. Alveolar mucosa. (From Liebgott B: The Anatomical Basis of Dentistry, ed 2, St. Louis, 2001, Mosby, Inc.) 5

Salivary Gland and Ducts (42300-42699) Three salivary glands Parotid Submandibular Sublingual Codes divided initially by gland Codes are divided based on the gland the procedure is performed on or the number of glands involved. Imaging guidance is reported separately. 6

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 Which category are the biopsies found in? (Excision, Destruction) Incision category is for peritonsillar abscesses. Figure: 18.10, A & B 7

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 non-endoscopic Diagnostic endoscopy always included in surgical endoscopy The key for billing removal of foreign bodies of the esophagus is the approach. What approach does code 43100 use? (Cervical) 8

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)

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) 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. Figure: 18.13 10

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) Be sure to watch for the codes listed as separate procedures 11

Endoscopy, Small Intestine and Stomal (44360-44397) Diagnostic bundled into surgical endoscopic Code to furthest extent of procedure 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) 12

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…) The notes define the specific terminology that should be used. In particular, read the notes preceding codes 45300-45392. 13

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) 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) 14

Colon Procedures & 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: G0107 G0104 G0105 G0106 G0120 G0122

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 Some headings include both laparoscopy (outside) and endoscopy (inside) procedures. 16

Hemorrhoidectomy and Fistulectomy Codes (46221-46320) Divided by Anatomy Subcutaneous: no muscle involvement Submuscular: splinter muscle Complex fistulectomy involves excision/incision of multiple fistulas 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) 17

Abdomen, Peritoneum, and Omentum Subheading (49000-49999) Laparoscopy Diagnostic (49320) Surgical (49321-49323) Repair category contains hernia repair codes The Abdomen, Peritoneum, and Omentum subheading includes a repair category that contains hernia repair codes. 18

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 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 areas that hernias may occur. (inguinal, umbilical, incisional, epigastric, lumbar) 19

Conclusion CHAPTER 18 DIGESTIVE SYSTEM 20