1. CHAPTER 18 DIGESTIVE SYSTEM

2. 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
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

3. Lips (40490-40799) Vermilionectomy (40500) is shaving of lip
Vermilion border: Area between lip and mucosal surface of mouth
Large defects ( )
Repaired with procedures such as transverse wedge excision (40510)
Cheiloplasty is lip repair
Full thickness repair ( )
Cleft lip repair ( )
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

4. 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

5. Dentoalveolar Structures and Palate/Uvula
Bone (osseous) and soft structures of mouth
Anchors teeth
Palate/Uvula ( )
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

6. 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

7. Pharynx, Adenoids, and Tonsils (42700-42999)
Incision codes initially divided on approach
Intraoral
External
Tonsillectomy and adenoidectomy
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

8. 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 use? (Cervical) 8

9. 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 ( )
If scope passes beyond second portion of duodenum, becomes an ERCP procedure ( )

10. Stomach (43500-43999) Gastric bypass performed for morbid obesity
Many different types, such as RNY
May be performed via laparoscope
Bariatric surgery ( )
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

11. 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

12. 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

13. 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
(Cont’d…)
The notes define the specific terminology that should be used.
In particular, read the notes preceding codes 13

14. Endoscopy Terminology
(…Cont’d)
Sigmoidoscopy: Entire rectum, sigmoid colon, and may include part of the descending colon (up to 26 inches or 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

15. 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

16. 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 ( )
Use of gastric band and/or subcutaneous port components
Some headings include both laparoscopy (outside) and endoscopy (inside) procedures. 16

17. 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

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

19. 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
Hernia repairs performed through laparoscopy are reported by means of codes
Name some areas that hernias may occur. (inguinal, umbilical, incisional, epigastric, lumbar) 19

20. Conclusion CHAPTER 18
DIGESTIVE SYSTEM 20