1. Digestive System
Digestive System

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3. Objectives
Define and understand the key terms associated with the digestive tract and the procedures performed in this section
Understand the anatomy associated with the procedures performed in this section
Explain the organization and content of the CPT® Surgery/Digestive System subsections
Learn to assign appropriately CPT® surgery codes from the digestive subsection

4. The digestive, gastrointestinal (GI) or alimentary, system (or tract) consists of the organs and glands associated with the ingestion, mastication (chewing), deglutition (swallowing), digestion and absorption of food and nutrients, and the elimination of waste products. The commonly called GI tract is a very long, hollow tube extending from the lips to the anus. It is covered by smooth muscle fibers that run circularly and longitudinally. Movement of food and waste products (feces) along the GI tract occurs via alternate circular contraction and relaxation of these muscles, this process is called peristalsis. The primary structures of the GI tract are the mouth, pharynx, esophagus, stomach, small intestine, large intestine, rectum, and anus. Affiliated or accessory structures include salivary glands, teeth, tongue, liver, gallbladder, and pancreas.

5. Digestive System Terms
Gastroenterology
Digestion
Absorption
Mastication
Study of the digestive system is referred to as gastroenterology. Digestion is the process by which ingested food is broken down into smaller particles for absorption. Absorption is the process by which nutrients are transported across the walls of the digestive tract into the blood for distribution throughout the body. Mastication breaks foodstuff into smaller pieces, which are chemically altered by digestive enzymes for absorption.

6. Digestive System Lips Entrance to the oral cavity Teeth
Begin mechanical digestion via chewing
20 Deciduous teeth
32 Permanent teeth
Gums
Tongue
Muscle
Facilitates chewing and swallowing
The teeth begin mechanical digestion via chewing. The salivary glands secrete saliva and enzymes; food is moisturized for swallowing. There are 20 deciduous teeth (baby teeth) that normally begin to appear individually around six months of age and are generally in place by two and a half years. The timing and order of teeth arrival is highly variable. Occasionally babies are born with a tooth or teeth. There are 32 permanent teeth that begin to come in pushing out baby teeth between ages six through 12. The three types of teeth are: incisors, cuspids, and molars. The top or visual portion of a tooth is the crown, the neck is surrounded by the gums, and the root is embedded in the mandible (lower) and maxilla (upper). The outer surface of the root is anchored by cementum, which holds the tooth in place. The bulk of the tooth is dentin. Pulp is on the inside and is composed of connective tissue, blood vessels, and nerves that give the tooth sensation. Enamel covers the crown. The dental formula for permanent teeth is two incisors, one canine, two premolars, and three molars on each half of the jaw. First permanent teeth are usually a molar.
The gums (gingiva) are fibrous structures surrounding the necks of the teeth. They are composed of fairly dense connective tissue covered by mucous membrane. Inflammation of the gingiva is gingivitis. Stomatitis is inflammation or ulcers of the mouth, including the mucous membranes, lips, and tongue.  
The tongue is a muscular organ, the midline fold of mucous membrane on the inferior surface is the frenulum or lingual frenulum; it anchors the tongue to the floor of the mouth and keeps us from swallowing it. The tongue facilitates chewing and swallowing by pushing food posterior. It also contains taste buds.

7. Digestive System Pharynx Conduit for respiration and digestion
Composed of:
Nasopharynx
Oropharynx
Laryngopharynx
Esophagus
Conduct food from the pharynx to the stomach
Peristaltic action moves the food
The pharynx (throat) lies between the mouth and nasal cavities superiorly and the esophagus below. It is the conduit for respiration and digestion. It is composed of the nasopharynx, the oropharynx, and the laryngopharynx. The nasopharynx is not part of the GI tract. Food does not normally enter the nasal or respiratory passages because swallowing temporarily closes off the opening to the nasopharynx.
The esophagus is a muscular tube approximately 10 inches long serving to conduct food from the pharynx to the stomach after it has been chewed and mixed with saliva in the mouth and swallowed. Peristaltic action of esophageal muscles serves to push the food along.

8. Digestive System Stomach: Cardia Fundus Pylorus (antrum) Body
The stomach is a large and very mobile temporary reservoir for food until digestion has proceeded to the extent it can be released into the duodenum. The parts of the stomach are the cardia (entrance), fundus (superior to cardia), pylorus (also called antrum, adjacent to pyloric sphincter and controls the release of food from the stomach), and body, comprising the remainder of the organ. Digestion occurs primarily in the stomach and duodenum.

9. Digestive System Small Intestine (small bowel) Duodenum Jejunum Ileum
Large Intestine (large bowel)
Cecum (appendix attached)
Colon
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Rectum
Anus
The small intestine (or small bowel) is the principal site of chemical compound absorption. It contains villi and microvilli that are surrounded by capillaries and lymphatic vessels. The end products of digestion enter these capillaries, and then go to the liver for processing. The small bowel extends from the pylorus of the stomach to the ileocecal junction to join the large bowel. It is about 20 feet long and is composed of the duodenum, jejunum, and ileum. Besides receiving digested food (called chyme) from the stomach, the duodenum receives secretions from the liver, gallbladder, and pancreas via small ducts. The ligament of Treitz is a thick band of muscle and fibrous tissue that suspends the distal portion of the duodenum; it is frequently mentioned as a landmark in operative reports. Even though it is only about 12 inches in length, much of the absorption occurs here. It is shaped like the letter C. The jejunum is next; at about 8 feet long, it connects the duodenum to the ileum as absorptive processes continue. The transition from jejunum to ileum is gradual. The jejunum is thicker walled and tends to be empty compared to the ileum. The ileum is about 12 feet in length and contains lymph tissue called Peyer’s patches that decrease the bacterial content in the digestive system. The ileum terminates in the ileocecal valve connecting to the large bowel.
The large intestine (or large bowel) is about 5 feet in length with a diameter of 2.5 to 3 inches. The ileocecal valve prevents reflux back into the ileum. It is comprised of the cecum, on the right side with the appendix attached. The appendix is a worm-like structure about 4 inches in length. Appendicitis is acute inflammation of the appendix and can be a medical emergency requiring appendectomy. Next is the colon consisting of ascending colon, transverse colon, descending colon, sigmoid colon, rectum, and anus. The rectum is the fixed terminal part of the large intestine and continuous with the sigmoid colon. The rectum is continuous with the anus or anal canal. The large intestine serves as a storage area for unabsorbed waste material (feces), where water is removed. When feces expel slowly, we call it constipation, when expelled rapidly it is called diarrhea. Bacteria are normally present in the colon. This is referred to as normal flora. 

10. Digestive System Spleen Blood-forming early in life
Acts as a storage organ and filter for blood later in life
Pancreas
Endocrine and exocrine organ
Secretes insulin into the bloodstream
Next are organs vital to the digestive system processes. The spleen, a purplish wrinkled organ about the size of a clenched fist, is found in the upper left quadrant of the abdomen between the stomach and diaphragm. This mobile lymphatic organ is blood-forming early in life, and later acts as a storage organ and filter for blood. Breakdown of erythrocytes (or red blood cells (RBCs)) occurs here. The most common reason for removal of the spleen (splenectomy) is trauma.
The pancreas is both an endocrine (hormone secretion - insulin) and exocrine (important digestive enzymes into the duodenum) organ, located just below the stomach. A flat organ, is about 6 inches long and 1 inch thick. It secretes insulin into the bloodstream and exerts a significant influence on carbohydrate and fat metabolism. The pancreas can have inflammatory diseases (pancreatitis), endocrine disorders (diabetes mellitus), and cancer. It is divided into a head, body, tail, and uncinate process.

11. Digestive System Liver (Hepatic) Largest organ and largest gland
Vital functions include:
Storage of glucose as glycogen, fat-soluble vitamins, and vitamin B12
Making of plasma proteins
Excretion of bilirubin, cholesterol and drugs
Metabolism of carbohydrates, protein and fats
Making of bile salts
Detoxification of drugs and other harmful substances
Gallbladder
The liver is the largest organ and the largest gland in the body. It is located in the right upper quadrant of the abdominal cavity in direct contact with the diaphragm and is protected by the ribs, crossing the midline. Hepatic refers to the liver. It varies in size, weighing about 4 pounds, and is reddish brown. It has four lobes: right and left lobes, separated by a (falciform) ligament; and the quadrate and caudate lobes. It is essential for life. Some vital functions include:
Storage of glucose as glycogen, fat-soluble vitamins (A, D, E, and K), and vitamin B12
Making of plasma proteins which play a vital role in blood volume and coagulation
Excretion of bilirubin, cholesterol, and drugs
Metabolism of carbohydrates, protein, and fats
Making of bile salts important in fat digestion and absorption of fat-soluble vitamins (This is the main digestive function of the liver.)
Detoxification of drugs and other harmful substances
A unique quality of the liver is regeneration: If a portion of the liver is removed, it will grow back.
The gall bladder is a pear-shaped organ attached by connective tissue to the inferior surface of the liver. Its posterior surface is close to the duodenum. It is a storage place for bile that becomes concentrated via water loss. Bile is secreted by the liver and has many digestive functions. The body of the gall bladder narrows into a neck that continues as the cystic duct. This duct joins with the common hepatic duct to form the bile duct that empties into the duodenum. These biliary ducts are vitally important. If the gall bladder is removed (cholecystectomy) due to stones or inflammation (cholecystitis), bile is sent directly from the liver to the duodenum.

12. ICD-10-CM Chapter 1 – Infectious and Parasitic Diseases
Chapter 2 – Neoplasms
Chapter 11 – Disease of the Digestive System
Chapter 17 – Congenital Anomalies
Chapter 18 – Signs, Symptoms, and Ill-Defined Conditions
ICD-10-CM
Many of the diagnoses codes for the digestive system are found in ICD-10-CM chapter 11, Diseases of the Digestive System (K00-K95). There are no chapter-specific coding guidelines for these conditions. Useful codes for reporting are not all grouped in one section of ICD-10-CM. There are chapter-specific guidelines for Infectious and Parasitic Diseases in chapter 1 and for Neoplastic Diseases in chapter 2.
Diagnosis codes in chapter 11 will be discussed followed by other helpful sections that will be identified as they are discussed. Most of these codes are straightforward and only need to be found. What follows will be a brief description of some of the conditions impacting the digestive system.

13. Disease of the Digestive System
Dental Specialists:
General dentist
Periodontist
Endodontist
Orthodontist
Oral Surgeon
9. Diseases of the Digestive System (K00-K14)
Diseases of Oral Cavity, Salivary Glands, and Jaws (K00-K14)
Anyone that has ever had a toothache understands the importance of these codes. It is useful to speak the “dental language” to understand what is going on. Specialists caring for these conditions include the general dentist, periodontist (care of normal tissues, gums, and supporting tissue around teeth), endodontist (care of diseases and injuries of the dental pulp and periapical tissues – root canals), orthodontist (correction and prevention of malocclusion – straightening of teeth), and oral surgeon (diagnosis and treatment of diseases, injuries and deformities of the oral and maxillofacial region). Depending on their skill and training, general dentists treat many of these issues, or they refer difficult cases or procedures to specialists in those areas.
Many dental practitioners specialize in a very specific area; they may only use a few codes. For the general dentist, (K02, Dental caries and K03 Diseases of hard tissues of teeth) may contain the diagnoses they report primarily. Other providers specialize in and care primarily for patients with temporomandibular joint (TMJ) pain or dysfunction patients (M26-M27). This is a chronic impairment of function of the articulation between the temporal and the mandibular bones.

14. Diseases of the Digestive System
GERD
Appendix
Appendicitis (K35-K38)
Peritonitis (K35.2)
Abscess (K35.3)
Gastro-esophageal reflux disease (GERD) is reflux (or backward flow) of stomach contents into the esophagus. It is characterized by a burning sensation called heartburn or pyrosis. Two codes, K21.0 and K21.9, can be confusing. Read the descriptors carefully. The difference is if esophagitis is present K21.0, GERD with esophagitis, or K21.9, is GERD without esophagitis.
Appendicitis (K35-K38) codes report an interesting and sometimes fatal diagnosis, defined as inflammation of the vermiform (worm-like) appendix. The function of the appendix has been debated for years. The serious nature of the problems associated with the appendix, peritonitis (K35.2), abscess (K35.3), can be understood remembering that this small structure is attached to the cecum. This portion of the large bowel contains serious potential contaminants, bacteria. The contents of the bowels are safe inside the intestines and the bacteria are part of the normal function (normal flora). If spilled into the abdominal or peritoneal cavity, things change. This is the case with a ruptured appendix. Peritonitis (K35.2, K35.3) is inflammation of the peritoneum, the layer that coats internal organs like the bowel, bladder, and the female the reproductive organs. The result can be shutdown of these organs, bowel obstruction, and scar tissue resulting in chronic pain or infertility. Amazingly, the diagnosis can be difficult to make many cases begin mildly and seem like a viral flu. Pain may be localized to the right lower quadrant of the abdomen. With rupture, the pain changes and involves the whole abdomen. “Rebound pain” is part of a physical exam where you push down gently on the abdomen resulting in mild discomfort. When you release the pressure there is severe pain. Hitting bumps while riding in a car on the way to the emergency room (ER) can be extremely painful, caused by the rebound pain. Appendicitis can feel similar to a viral illness, ovarian cysts, ectopic pregnancy, constipation, and even severe dehydration. Many patients have been taken to surgery for one of these problems only to discover appendicitis; the reverse scenario is also seen. Imaging tests have gotten more useful in the diagnosis; however, surgery is still sometimes required to know for sure. There has been much discussion about the “incidental appendectomy.” When you are doing surgery for another problem, why not take out the appendix, even if it appears healthy? Can or should you report it? Get paid for it? There is more on this later.

15. Diseases of the Digestive System
Hernia of the abdominal cavity (K40-K46)
Inguinal
Femoral
Umbilical
Abdominal
Diaphragmatic
Diverticula of intestine (K57)
Diverticulosis
Diverticulitis
Fissures and fistulas (K60)
Hernia of the Abdominal Cavity (K40-K46) can describe more conditions than you would think. Hernia is defined as a protrusion of a part or structure through the tissues normally containing it. Usually we think of an inguinal (K40) or femoral (K41) hernia in the groin. Due to anatomical differences between men and women, men more often get inguinal hernias; women more commonly get femoral hernias. Hernias can be umbilical (K42), of the abdomen or incisional (K43), or diaphragmatic (K44). A serious complication of hernias involves the small bowel. Due to the weakness in a containing wall, the small bowel can protrude through, and then become trapped or the blood supply to the bowel can be compromised. Complications resulting can include intestinal obstruction and even death and gangrene of a trapped (also called strangulated) segment of bowel.
Diverticula of intestine (K57) occurs with a pouch or sac opening from the bowel. Diverticulosis is the presence of a number of diverticula of the intestine. Diverticulitis is inflammation of the diverticulum, the small pockets in the wall of the small bowel filled with stagnant fecal material that can become inflamed, cause obstruction, perforation, or bleeding. It primarily affects middle-aged and elderly people. Codes are based on the site of the condition, with or without a perforation or abscess, and whether or not there is bleeding.
Fissures and fistulas of the bowels can be very difficult. A fissure is a deep cleft, furrow, or slit. A fistula is an abnormal passageway. When involving the anus (K60), these conditions create problems because of the contamination with bacteria in feces. Chronic conditions can result due to difficulty in healing with recurrent contamination of the area. Abscesses (K61) can occur and surgical procedures may be required.

16. Diseases of the Digestive System
Hepatitis
Acute
Chronic
Classifications
Cirrhosis
Chronic Alcoholism
ICD-10-CM codes range from K70-K77 for Diseases of the liver.
Hepatitis is inflammation of the liver (synonym – hepatic), usually from a viral infection. It can be acute or chronic in nature. Classification of hepatitis can be confusing, several types of viral hepatitis occur including: hepatitis A, spread by oral-fecal route; hepatitis B via contact with contaminated fluids such as blood or other body fluids with sexual contact; hepatitis C with contaminated blood in transfusions, or needles in drug use or to health care workers in accidental “needle sticks.” It is estimated that 2.7 million people in the United States are chronically infected with hepatitis C. Other types of hepatitis include hepatitis D, which occurs in someone already infected with hepatitis B; hepatitis E is similar to hepatitis A and is rare in the United States, but endemic in some parts of Asia, Africa, the Middle East, Central America, and Mexico. Hepatitis G occurs in people with hepatitis B or C. Hepatitis is often abbreviated by initials such as hepatitis B is HBV referring to hepatitis B virus. Cirrhosis can be caused by hepatitis or chronic alcoholism. Cirrhosis is end stage liver disease characterized by diffuse damage to the liver structure (or parenchyma) with fibrosis and loss of the normal architecture. The function of hepatic cells (or hepatocytes) fails. The liver becomes firm or fibrotic; this can result in jaundice, a yellowing of the skin mucous membranes, and conjunctive by circulating bile pigments. Jaundice is also referred to as icterus. Chronic hepatitis can result in liver cancer.

17. Diseases of the Digestive System
Cholelithiasis
Cholecystitis
Neoplasms
Cholelithiasis (K80) is the presence of stones (calculi, or concretions) in the gallbladder or bile ducts. Small stones in the gallbladder may not cause problems. When found in the ducts, pain can be severe. Cholecystitis is inflammation of the gallbladder. Stones can be present without cholecystitis; ICD-10 codes are available to report both conditions. “Biliary calculus or calculi” indicates a stone(s) in the gallbladder ducts.
Start with the alphabetic index to code benign and malignant neoplasms of the GI tract. Next, go to the Neoplasm table for specific codes. Cancer of the pancreas (C25) is very serious and often fatal within months. Why is that? The answer is anatomy; the pancreas is tucked in snuggly below the stomach, in the curve of the duodenum with the tail near the spleen in the upper left quadrant of the abdominal cavity. Symptoms of this cancer can be vague and non-specific; it may just be mild to severe back pain or jaundice. This cancer metastasizes to the liver early and spreading has often already occurred before the cancer is detected. By the time this cancer is found, surgery may not be possible.

18. CPT® Organized by anatomic site and procedure Endoscopy
Visualization of a hollow viscus or canal by means of an endoscope or scope
Laparoscope is an endoscope
CPT® of the Digestive System ( )
The digestive system subsection of CPT® contains diagnostic and treatment procedures of the GI system divided by anatomic site and procedure. Just as the anatomy, section began with the lips and travels to the anus, so does CPT®. Codes are included for accessory organs such as the liver, gallbladder, and pancreas. Many of the GI procedures involve endoscopy. Endoscopy is visualization of a hollow viscus (organ) or canal by means of an endoscope or scope. Endoscopy is useful for both diagnostic and therapeutic purposes. A laparoscope is an endoscope; often these terms are used interchangeably.

19. CPT® Lips (40490-40799) Vermilionectomy Cheiloplasty
Vestibule of Mouth ( )
Vestibuloplasty
Repair of lacerations
Frenectomy
Beginning with the lips, codes are listed for Excision, Repair, and Other Procedures. Vermilionectomy (40500) is excision of the red (or lipstick region) margin of the upper and lower lips. This is different from a cheiloplasty ( ), which is a plastic surgery of the lips. Look carefully at the codes for repair of cleft lip; some report unilateral procedures and others are used for bilateral procedures. There are parenthetical instructions to be reviewed for these codes, as well. The Vestibule of Mouth ( ) is the space between the cheek, lips, and teeth; it is also called the buccal cavity. A vestibule is a small cavity or space at the entrance of a canal, in this case the mouth. Listings include Incision; Excision, Destruction, Repair and Other Procedures. A vestibuloplasty ( ) is a plastic repair performed in the vestibule of the mouth. The repair category codes are used to report lacerations of the vestibule of the mouth and vestibuloplasties. Documentation by the provider is critical; size of the laceration determines the code. The frenum (or frenulum) is folds of mucous membrane in the mouth attaching the lips to the gums; when cut or excised it is a frenectomy (40819).

20. CPT® Tongue and Floor of Mouth (41000-41599) Incision Intraoral I & D
Extraoral I & D
Frenotomy
Excision
Biopsy
Excision of Lesion
Removal of all or part of tongue
Repair
Tongue and Floor of Mouth ( ) is the next subheading of codes. Abscesses, cysts, or hematomas in this area are coded by location. For example, superficial, deep, submental, submandibular, or masticator are all possible locations reported with different codes. It is interesting to note that the first group listed ( ) are intraoral; extraoral ( ) codes listed next are found outside of the mouth. An example is incision and drainage (I&D) of an abscess under the chin. Frenotomy (41010) here is specified as “incision of lingual frenum”.
The Excision category ( ) includes codes for oral biopsies, excision of oral lesions, and the removal of all or part of the tongue. Location of the lesion determines the code. Glossectomy ( ) is removal of all or part of the tongue. This is another example of the importance of documentation by the provider. You need to know how much tongue was removed to choose the correct code. Cancer of the tongue is the main reason for this drastic procedure. Repair category ( ) includes repair of lacerations to the tongue and the floor of the mouth. Particular code choice is based on the size of the laceration.

21. CPT® Dentoalveolar Structures (41800-41899)
Gums (or soft tissue structures)
Bone that anchor the teeth
Palate and Uvula ( )
Roof of the mouth
Uvula – posterior edge of the middle of the soft palate
Salivary gland and ducts ( )
Codes based on gland
Dentoalveolar Structures ( ) are the gums (or soft tissue structures) and bone that anchor the teeth. Conditions reported here include I&D of abscesses, cysts, hematoma, or excision of a lesion with a simple repair. Some of the codes are based on the quadrant in which the procedure is performed.
Palate and Uvula ( ) report procedures on the roof of the mouth and the uvula. The uvula (or palatine uvula) is the posterior edge of the middle of the soft palate. When you say, “ah,” it is the conical wedge of tissue hanging down from the top of your mouth at the back. There is only one code for incision. The Excision, Destruction category is used to report excision of lesions. If skin grafting is necessary to repair the defect of the excision, the grafting procedure is reported in addition to the excision. The graft code is chosen based on if the graft was a skin graft or a mucosal graft. Uvulectomy (syn – staphylectomy) is removal of the uvula (42140). Also listed here is a palatopharyngoplasty (42145).
Salivary gland and ducts ( ) codes are divided into Incision, Excision, Repair, and Other Procedures. The codes in these categories are divided based on the gland. For example, incision for drainage of a parotid abscess is 42300, and the incision and drainage of a submaxillary or sublingual abscess is If imaging is required, this guidance is reported in addition to the biopsy and will be based on the type of imaging.

22. CPT® Pharynx, Adenoids and Tonsils (42700-42999) Tonsillectomy
Adenoidectomy
Biopsy
Pharyngoplasty
Pharyngostomy
Pharynx, Adenoids and Tonsils ( ) includes tonsillectomy and adenoidectomy. Other codes for biopsy pharyngoplasty and pharyngosotomy are listed, as well. Some of these terms can be intimidating, so break them down to their roots and keep a good medical dictionary handy. Tonsils are lymph nodes in the throat area that filter tissue fluid for pathogens that enter the body trough the nose or mouth or both. Palatine tonsils are removed with a tonsillectomy ( ), they are found at the opening of the oral cavity into the pharynx. Adenoids are pharyngeal tonsils located near the opening of the nasal cavity in the upper pharynx. When enlarged, the adenoids may interfere with breathing; removal is adenoidectomy ( ). The age of the patient is also a factor in code selection. Another factor for code selection is whether it is primary or secondary (tissue has grown back). There is controversy regarding tonsillectomy procedures and when they should be performed.
A pharyngoplasty is the surgical repair of the pharynx. This procedure is plastic surgery of the pharynx. And can involve flaps from the mucous membranes, tongue, and tissue near the area of defect.
A pharyngosotmy is a procedure to create an opening for insertion of a long-term feeding tube. Pharyngostomy is necessary with severe facial trauma. If you need to report the control of oropharyngeal or nasopharyngeal hemorrhage, codes from the “Other Procedures” subheading is used. These codes are selected based on whether it is a primary or secondary procedure and the level of complexity.

23. CPT® Esophagus (43020-43499) Incision Esophagotomy – based on approach
Cricopharyngeal myotomy
Excision
Lesion excision – based on approach
Endoscopy
Watch indented codes…brackets may be useful here
ERCP – Endoscopic Retrograde Cholangiopancreatography
Esophagus ( ) is a large section. There are only two incision codes for removal of a foreign body that are chosen based on approach (cervical 43020, thoracic 43045). A cricopharyngeal myotomy is a surgical procedure for the treatment of cricopharyngeal achalasis is a disorder of the esophagus preventing normal swallowing. The Excision category ( ) contains codes for lesion excision dependent on approach. It is important to read the code descriptions and pay attention to the use of “with” and “without” as well as parenthetical instruction for the use of modifiers. There are also notes referring you to other codes for specific procedures.
We discussed endoscopy earlier; in the esophagus ( ) procedures are performed to diagnose and/or treat conditions of the esophagus and the hepatobiliary system. You’ll also note that in many instances the code with the common portion of the procedure is followed by several indented procedures. For example, code is an Esophagoscopy, rigid or flexible; diagnostic, followed by 14 indented codes. Read these carefully to make sure you select the appropriate code. Some of these codes do not include imaging guidance. Code is an example of a procedure that doesn’t include imaging. If imaging guidance is used, report in addition to Procedure does include imaging and you’ll see that the parenthetical instructions tell you not to report it. The codes to describe upper GI procedures are similar in format to the esophagoscopy codes in that there are many indented codes following the “common portion” of the procedure and instructions on imaging guidance.
An ERCP is an endoscopic retrograde cholangiopancreatography (43260) (The abbreviation is a good idea!). This technique may be used to obtain a biopsy or a procedure to relieve a biliary obstruction. Codes are selected based on if the procedure was diagnostic or included in a therapeutic procedure such as dilation.

24. CPT® Esophagus (43020-43499) cont. Repair
Codes selected based on approach
Manipulation
Dilation of esophagus
Report S & I in addition
In the Repair category are codes to report plastic repair or reconstruction on the esophagus and codes for esophagogastrostomy, esophagostomy and esophagojejunostomy. Many of these codes are selected based on the approach and you’ll need to know if it was abdominal, thoracic, or cervical.
Manipulation ( ) category contains codes for dilation of the esophagus by various methods. If radiological supervision and interpretation is performed with the procedure, report it in addition to the manipulation code. Note the parenthetical instructions direct you to the appropriate code in the radiology section.

25. CPT® Stomach (43500-43999) Incision Foreign body removal
Excision of stomach tumor
Excision
Gastrectomy
Total or partial
Additional procedures performed
Introduction
Placement, changing and repositioning of feeding tubes
Bariatric Surgery
Other Procedures
Stomach ( ) subheading includes incisional procedures to expose the stomach to the surgeon for the removal of a foreign body, or to excise a stomach tumor. A gastrectomy is the removal of all or part of the stomach. Code selection for gastrectomy is based on whether it’s total or partial, and further defined by other procedures performed at the same time. For instance, a total gastrectomy with formation of intestinal pouch, any type is 43622, while a total gastrectomy with esophagoenterostomy is reported with Some surgical procedures on the stomach may be carried out laparoscopically. Remember: Surgical laparoscopy always includes diagnostic laparoscopy.
The Introduction category of the stomach contains codes for the placement, changing, and repositioning of feeding tubes. Code includes the fluoroscopy, image documentation and report , you would not report it separately. For repositioning of the gastric feeding tube, you are instructed to report if imaging guidance is performed. There are numerous parenthetical instructions in this category that should be read carefully. 
Bariatric surgery ( ) is defined as surgery supporting weight loss by changing the digestive system’s anatomy and limiting the amount of food that can be eaten and digested. These codes are found within the Laparoscopy category. Report for the placement of the adjustable gastric restrictive device. The remaining codes are for removal, replacement, or adjustment of the device.
The other procedures category ( ) contains open surgical procedures on the stomach. A gastric bypass for morbid obesity is reported with An open gastric restrictive procedure with revision of subcutaneous port is reported with 43886; removal of the port is reported with 43887, while removal and replacement of the port is reported with

26. CPT® Intestines (except rectum) 44005-44799 Incision Biopsy
Exploration
Excision
Enterectomy
Laparoscopy
Intestines (except rectum) ( ) lists separate procedures and a number of add-on codes. A reminder, add-on codes are used in addition to the primary procedure and would not be reported alone. The incision category ( ) lists intestinal procedures that include biopsy and exploration. A colotomy for exploration, biopsy(s) or foreign body removal is reported with If the duodenum is the location of biopsy(s), exploration, or foreign body removal, the correct code is An enterectomy is a resection of the intestine and is found in the Excision category. Enterectomy means a diseased portion of the intestine is removed. When the diseased portion is removed, the remaining ends are either joined directly (anastomosis) or an artificial opening is developed through the abdominal wall (exteriorizing). The type of anastomosis or exteriorization depends on the medical condition of the patient and on the amount of intestine removed. Many procedures on the intestine may be done by laparoscopy. Some examples are laparoscopic ileostomy or jejunostomy and laparoscopic enterectomy, resection of small intestine. The closure of an enterostomy, large or small intestine, with resection and anastomosis can also be performed using surgical laparoscopy.

27. CPT® Enterostomy (44300-44346) Temporary or permanent
Classified according to the part of the intestine used to create the stoma
Endoscopy, Small Intestine (44360 – 44379)
Distinguish if performed through stoma
Repair ( )
Enterostomy codes are reported with An enterostomy is an operation to make a passage into the patient’s small intestine through the abdomen with an opening to allow for drainage or to insert a tube for feeding. The opening is called a stoma. Enterostomies may be either temporary or permanent and are classified according to the part of the intestine that is used to create the stoma. If the ileum is used to make the stoma, it’s called an ileostomy. If the jejunum is used, it’s called a jejunostomy. To choose the correct code, you will need to know the anatomic site that the ostomy originated.
The Endoscopy category in the digestive system consists of codes to report diagnostic or surgical procedures on the small intestine and stomal endoscopies. These procedures are used to report the removal of a foreign body, ablation of tumors and biopsies. You’ll want to distinguish in the operative report whether the procedure was performed through a stoma.
If bleeding occurs as the result of an endoscopic procedure, control of bleeding is not reported separately during the same operative session. When a physician performs a diagnostic or screening endoscopy on a patient who is scheduled and prepared for a total colonoscopy and the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report the appropriate code (45378 or 44388) with modifier 53 and provide appropriate documentation. When a therapeutic colonoscopy is performed and does not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52.
The Repair category contains sutures of intestines for perforated ulcer, diverticulum, wound injury, or rupture. Report for the suture of small intestine, single perforation; report for the suture of large intestine, single or multiple perforations.

28. CPT® Meckel’s Diverticulum and the Mesentery (44800-44899)
Appendix ( )
Meckel’s Diverticulum and the Mesentery ( ) are next. An Meckel’s diverticulum is a congenital pouch (diverticulum) located at the lower (or distal) end of the small intestine. The excision of Meckel’s diverticulum is reported with 44800; the excision of a lesion of the mesentery is reported with
Appendix ( ) codes include open procedures (often called laparotomies or exploratory laparotomies), percutaneous procedures, and laparoscopic (or endoscopic). During an intra-abdominal surgery, the appendix is “incidentally” removed; you would not report the appendectomy in addition to the primary procedure. Refer to the notes beneath regarding an incidental appendectomy.

29. CPT® Rectum (45000-45999) Incision – drainage of abcesses Excision
Proctectomy – partial or complete
Endoscopy
Proctosigmoidoscopy
Sigmoidoscopy
Colonoscopy
Anus ( )
Rectum ( ) subheading lists the usual categories: incision, excision, and endoscopy. The incision category contains codes for drainage of the abscesses. The excision category includes codes for excision of the rectum (proctectomy). Proctectomy codes are differentiated by partial or complete as well as other procedures that may be performed at the same time. Rectal endoscopies are divided based on the extent and purpose of the procedure. Proctosigmoidoscopy is the examination of the rectum and the sigmoid colon; sigmoidoscopy is an examination of the sigmoid colon and may include the descending colon; colonoscopy is the examination of the colon from the rectum to the cecum and may include the ileum. The stand-alone codes 45300, 45330, and each have indented codes based on the purpose such as biopsy, foreign body removal, etc. If bleeding occurs as the result of an endoscopic procedure, control of bleeding is not reported separately during the same operative session. A colonoscopy decision tree is located in the Digestive section of CPT® to aid in determining the type of procedure as well as proper code assignment based on how far the provider was able to advance the scope. When a physician performs a diagnostic or screening endoscopy on a patient who is scheduled and prepared for a total colonoscopy and the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report the appropriate code (45378 or 44388) with modifier 53 and provide appropriate documentation. When a therapeutic colonoscopy is performed and does not reach the cecum or colon-small intestine anastomosis, report the appropriate therapeutic colonoscopy code with modifier 52.
Anus ( ) lists codes to report abscesses of the anus, which are common conditions. They are usually treated with I&D and found in the Incision category. Seton is a material such as thread, wire, or gauze. The placement of a seton (or marker)—code 46020—is a treatment for anal fistula. As described earlier, a fistula is an abnormal passage between the anus and the skin and usually the result of a previous abscess that has not healed. A suture is threaded through the fistula, out through the anus, and the ends of the suture are tied together. The seton is left in place until there is healing; removal of the seton is reported with
Excision category contains codes for hemorrhoidectomy and are selected based on if the hemorrhoids are external or internal as well as the complexity and if other procedures were performed during the same operation. An anoscopy is an examination of the rectum. A small tube is inserted into the anus to screen, diagnose, and evaluate problems of the anus and anal canal. Various procedures can be performed once the tube is inserted. The codes for the destruction of anal lesions are found in the code range and are selected based on the method of destruction.

30. CPT® Liver (47000-47399) Biliary Tract (47400-47999)
Pancreas ( )
Liver ( ) subheading includes codes for liver transplantation as well as procedures for liver biopsy and laparoscopy procedures. A biopsy of the liver that is done in a percutaneous manner using a needle is reported with You may also report the imaging guidance if it is performed. Refer to the parenthetical instructions for the choice of imaging guidance codes. Liver transplantation codes have important guidelines to follow when you are using these codes. The transplant involves several physicians and a trained surgical team. The procedure involves obtaining the graft to be transplanted (from a cadaver or living donor), backbench work, and transplantation into the recipient. Each component should be coded separately.
Biliary tract ( ) connects the gallbladder to the liver and the small intestine. It’s a common site for calculus and tumors that may obstruct the flow of bile. The incision category includes codes to explore the tract and may include removal of calculus or drainage of bile. An injection may be necessary to find out if the biliary tract is obstructed. If the injection is done percutaneous with new access is reported; if the injection was done through existing access, you would report
The codes in the Laparoscopy, is reported for a cholecystectomy. The Excision category is used if the gallbladder was removed through an incision with codes
Pancreas ( ) is a large gland located behind the stomach. To report placement of drains by incision, use The pancreas can also form calculus, which may be removed. Biopsies on the pancreas may be done with a percutaneous needle or open incision. The guidance in a percutaneous biopsy is not included in the code and is reported separately. The guidance code is selected based on the type of guidance used. The pancreas can be totally or partially removed. These codes are divided based on the extent of the removal and other procedures that may be done at the same operative session. The pancreas transplantation codes include harvesting the pancreas graft from a cadaver, backbench work in preparation for transplant, and transplant of the graft into the recipient.

31. CPT® Abdomen, Peritoneum, and Omentum (49000-49999)
Exploratory laparotomy (49000)
Drainage of abscess – open or percutaneous
Laparoscopy
Hernia codes
Type of hernia
Strangulated or incarcerated
Initial or subsequent repair
Abdomen, Peritoneum, and Omentum ( ) subheading contains the code for an exploratory laparotomy, described previously. This procedure is usually done when the nature of the disease isn’t known. Code may also be used if a biopsy is performed at the same operative session. Codes for drainage of peritoneal, subdiaphragmatic, and retroperitoneal abscesses are selected based on if they are completed by open procedure or percutaneously. The percutaneous procedures instruct the coder on the use of radiological supervision and interpretation codes.
The laparoscopy codes are used to report a surgical laparoscopy. Code is used to report a diagnostic laparoscopy of the abdomen, peritoneum, and omentum. A laparoscopy that includes surgical procedures such as biopsy or insertion of catheter, are reported with codes
Hernia codes are listed according to the type of hernia. Other aspects to consider in code selection are whether the hernia is strangulated or incarcerated, and whether the repair is an initial or subsequent repair. Age may also be a determining factor in code selection. As an example, the code for the repair of an initial inguinal hernia for a 4-year-old, reducible is If the hernia was incarcerated the code would be The same procedures on someone over the age of 5 years would be or Inguinal hernias may also be repaired with the use of a laparoscope. They are selected based on the type and if it is incarcerated or strangulated. If mesh is used, it is included and not coded separately.

32. HCPCS Colorectal cancer screening G0104-G0106 G0120-G0122 HCPCS
These codes are useful when a Medicare patient is screened for a malignant neoplasm of the GI tract found in HCPCS Level II. Codes G0104-G0106 and G0120-G0122 are used when performing a sigmoidoscopy, colonoscopy, or barium enema when screening for GI malignancies on Medicare patients.

33. Modifiers 50 – Bilateral 52 – Reduced services
53 – Discontinued procedure
Modifiers
Relevant modifiers to the digestive section are mentioned with the codes and their descriptions. Code repair of cleft lip lists the instruction, if bilateral procedure, report with modifier 50.  
The parenthetical notes for (partial esophagectomy, cervical with free intestinal graft) indicates that modifier 52 be appended if intestinal free jejunal graft with microvascular anastomosis is performed by another physician. Code gives instructions for use of modifier 52 with an incidental appendectomy.
There is a “coding tip” given regarding colonoscopy with regards to modifier 53 when the colonoscope cannot be advanced beyond the splenic flexure due to unforeseen circumstances.

34. The End