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Chapter 23 Step-by-Step

Digestive system subsection divided according to:

anatomic site and procedure

What is included in digestive system CPT codes?

sites beginning with the mouth and ending with the anus; internal organs that aid in digestive process including pancreas, liver and gallbladder; also codes for procedures of abdomen, peritoneum, omentum, and hernia repairs.

Where are endoscopic codes located in the digestive system CPT coding manual?

throughout the subsection on the basis of anatomical site


shaving of the lip;Depending on size of repair: surgeon removes an area of tissue and repairs the defect by moving the mucosal surface to reconnect the lip, therby forming a new vermilion border. (CPT code 40500)

vermilion zone

red part of the lips

transverse wedge excision

a wedge of lip tissue is removed and tissue flaps are placed to repair the defect (see CPT code 40510)


Abbe flap or cross flap is a reconstructive procedure in which a graft is taken from a portion of the lip and the non-defective area above lip is used to repair the area of the defect

lip resection

if more than 1/4 of lip surface is removed, procedure considered resection and reported with 40530)

complex repair of lip and face

CPT codes 13131-13153


lip repair

two types of lip repair codes

full-thickness repair of lip or cleft lip repair

cleft lip

congenital defect in which the muscle and tissue of the lip did not close properly

coding cleft lip repair with rhinoplasty

rhinoplasty may be required if nasal deformity has occurred with the cleft lip defect, rhinoplasty coded separately.

unilateral or bilateral cleft palate repair codes

if bilateral procedure performed and code description does not indicate bilateral procedure, add modifier-50.

coding cleft lip repair with palatoplasty

palate repair reported separately


palate repair

vestibule of mouth CPT codes

part of the oral cavity incisions, excision/destruction/repair.
Do not include codes for service of the tongue and floor of the mouth or dentoalveolar structures.

Tongue and floor of mouth CPT codes



under the mouth


under the mandible

masticator space

space from floor of mouth to the hyoid bone

lingual frenum

flap of skin under the tongue


tongue tie due to tight lingual frenum


incision in the lingual frenum


excision of the lingual frenum


lingual frenum surgically repaired (code from Other procedures category)

Extraoral incision and drainage

I & D performed on abscess, cyst or hematoma located outside the mouth and coding based on location of sublingual, submental, submandiublar or msticator space

oral biopsy

coding based on location from which biopsy obtained.


removal of all or part of the ginue

Excision coding for tongue and floor of mouth

if local tongue flap is required to repair excisonal defect, report repair with 41114 in addition to primary incision procedure

repair of tongue coding

based on size of repair 2.5 cm or less; over 2.6 cm, and in additon based on location of repair

Dentoalveolar structures

bone (osseous) and soft structures of the mouth that anchor the teeth. Codes report incision, excision/destruction and other types of procedures performed.

Dentoalveolar quadrants



excision of the gingiva

palate and uvula coding



palate and pharynx repair procedure which may be performed to OSA patients not responding to CPAP or other conservative measures


obstructive sleep apnea


shallow breathing

salivary gland and ducts - CPT coding

parotid, submandibular and sublingual salivary glands, coding may be divided by gland


x-ray of salivary gland

parotid duct

Steno's or Stensen's duct

pharynx, adenoids and tonsil's CPT coding

incision codes based on location,(
surgical approach: intraoral or external)

branchial cleft cyst

congenital defect that appears as a gill located on the neck

tonsillectomy and / or adenoidectomy coding

performed bilaterally:
If procedure reported with -50 modifier, or with modifieres-RT and -LT, the 3rd party payer will usually not recognize modifier's and pay based on amount for a single procedure
IF ONE SIDE ONLYis removed, modifier -52 (reduced service) must be appended to the cpT code


surgical repair of pharynx and includes the use of flaps fashioned form skin, tongue, and/or tissue located near area of defect used in repair procdure


procedure to create an opening for insertion fo a long-term feeding tube. incision made below jaw line on skin and incision is carred down to the parynx.


nasogastric feeding tube


between softr palate and the epiglottis


above the soft palate

esophagotomy or myotomy

coded based on whether the procedure is prinmary or secondary and level of complexity


surgical incision or division of a muscle

1) A _____is shaving of the lip.


2) In addition to the sites from the mouth to the anus, the Digestive System codes include codes for the pancreas, liver and _______.


3) How many centimeters are there in 4 inches (round to the nearest tenth)?


4) An Abbe-Estlander reconsgtruction for cleft lip.

CPT code:

5) A complex, full-thickness repair of the vermilion after resection of bucall-mucosal squamous cell carcinoma of upper lip.

CPT code

6) Simple drainage of a hematoma of the vestibule of the mouth

CPT code

7) Repair of a laceration of the tongue, measuring 1.5 inches.

CPT code

Pharynx, Adenoids and tonsils

codes 42700-42999

Incision category codes (42700-42725)

based on location and the approach utilized (intraoral or external)


around the tonsils


behind the pharynx


adjacent to the pharynx

biopsy category codes (42800-42806)

include obtaining biopsy sample but does not include use of a scope. If laryngoscopic biopsy is performed, the service is reported with code from Respiratory system

Procedures of the esophagus

Codes 43020-43499, performed by incision, excision, endoscopy, repair and manipulation. APPROACH determines code.

types of esophagus procedures

diagnostic endoscopy, injection, biopsy, removal of foreign body, insertion of plastic tube/stent, dilation, and hemorrhage control.

diagnostic esophagoscopy with endoscopic ultrasound examination

43231 include imaging guidance

excision codes (43100-43135

include cervical, thoracic and abdominal approaches


stricture at end of stomach

esophageal endoscopy

codes 43200-43232

diagnostic esophagoscopy

using either rigid or flexible scope, used with or without collection of specimen(s)

0 global days

procedure includes all preoperative and postoperative care related to performing the procedure on the day of the procedure; but before on after the day of the procedures, any services related to procedure are reported separately

esophagoscopy with submucosal injections of any substance of any substance

code substance injected

esophagoscopy (rigid or flexible) with biopsy (single or multiple)

code 43202 once (one unit) regardless of number of biopsies taken

diagnosis must support the medical necessity of procedure


radiology used during esophagoscopy

code separately

removal of ablation of esophageal polyp, tumor or othe rlesion

coded with 43216 or 43217 according to technique of removal


esophagogastroduodensocopy, procedure performed to examine esophagus, stomach, duodenum, and sometimes jejunum for signs of bleeding, tumors, erosion, ulcers, or other abnormalties

EGD code 43259 assigned when an endoscopic ultrasound examination is performed,

radiological supervision and interpretation is not reported separately


endoscopic retrograde cholangiopancreatography, procedure of the pancreatic ducts, hepatic ducts, common bile ducts, duodenal papilla, and/or gallbladder (Hepatobiliary system) primiarily to diagnose and treat conditions of the bile ducts, including gallstones, inflammatory strictures (scars), leaks (due to trauma or surgery), and cancer

ERCP coding

based on purpose of procedure: diagnostic or therapeutic, codes do not include radiological superivsion and interpretation, so when perform code 74328 (biliary ductal system), 74329 (pancreatic ductal system) and 74330 (biliary and pancreatic ductal systems)failed ERCP

Failed ERCP

coded 43260-52 indicating a service that was reduced at physician's discretion

laparoscopy (43279-43289)

surgical laporoscopy is a procedure to examine organs of the abdominal cavity and always includes diagnostic laparoscopy


thin flexible tube containing a camera, placed through a small incision in the abdomen

Stomach codes 43500-43999


gastric bypass surgery

outcome of decreasing size of stomach and/or intestines to aid with weight loss

Roux-en-Y (RNY)

Y-shaped surgical connecdtion in which the intestine is detached from its original origin an dreattached so as to bypass a part of the stomach and the entire duodenum

bariatric surgery

codes 43770-43775, gastric restrictive procedures


codes 44005-44799


creation of an artificial opening, always bundled into a more major procedure

resection of intestines

taking out a portion of intestine and joining the remaining ends (anastomosis) directly or developing an artifical opening (exteriorizing) through the abdominal wall


artifical opening

openings to the outside of the body are named for the part of the intestine from which they are formed

colostomy, ileostomy, gastrostomy

1. The first step to choosing the correct GI endoscopic code is to determine the _____to which the scope was passed.


if exploratory procedure progressed to surgical treatment

code the definite treatment


endoscopic examination of the entire rectum and sigmoid colon and may include part of the descending colon

if a definitive diagnosis has not been documented

report the documented signs/symptoms

diagnostic colonoscopy

endoscopic examination fo the colon from rectum to cecum. Coded based on extent and purpose of procedure

modifier -53

discontinued procedure, with documentation


endoscope is advanced to the proximal colon (past the splenic flexure) to the cecum or into a protion of the terminal ileum (most distant part of the small intestine)

cold biopsy

use of forceps to grasp and remove a small piece of tissue without the application of cautery.

snare procedure

wire loop is placed around the lesion and the wire is ten heated to shave off the lesion. Report only one technique for each lesion or polyp.


surgical removal of a polyp

if single lesion is biopsied, but not entirely removed

only biopsy code assigned

if biopsy obtained and lesion is also excised

only excision of lesion coded

with or without biopsy

biopsy not reported separately


no presenting symptoms or disease is present

ablation of lesion

destroy entire lesion

colonsocopy injection

code 45381 when polyp is injected with saline to lift polyp prior to removal by another technique

other injection services

placement of tattoo with India ink for later identificaion of the area during a surgical procedure



bleeding caused by the procedure and controlled by any method is considered part of the therapeutic procedure and not coded separately


multiple lesions removed from colon using same technique (snare)

use only one code to report the service, colon is considered on anatomical location. If procedure is prolonged or extensive, report modifier -22 and include time procedure extned beyond usual time with documentation with claim form to support assignment of modifier


virtual colonoscopy utilizes x-rays and computer to produce a 2 and 3-D image of the colon used to diagnose colon and bowel disease. Performed without sedation and in radiology department. Also used as a technique for screening.

Virtual colonoscopy

can be performed with CT, MRI


acquired malformation of mucosal and submucosal capillary beds, usually arises in cecum and right colon due to high wall tension, rupture classically presents as hematochezia in an older adult


passage of stools containing bright red blood

1) Appendectomy on a patient with a ruptured appendix

CPT code:

2) Flexible sigmoidoscopy with 3 biopsies

CPT code

3) Colonscopy with removal of polyp by a snare

CPT code

4) The patient presents for removal of a sigmoid and rectal polyps. The Pentax video sigmoidoscope was inserted and four polyps were seen scattered between the rectum and proximal sigmoid colon. The largest measured about 1.5 cm in diameter. The others were diminuitve, about 4 of 5 mm in diameter. Biopsies were taken of 2 of these polyps. The pathology report indicated benign polyps.

CPT code:


treatment for anal fistula

anal fistula

abnormal passage between anus and skin which is usually the result of a previous abscess that has drained but not completely healed.


cleft or a groove, normal or otherwise

anal fissure

painful ulcer usually located at the margin of the anus


excision of the fissure


surgical incision of a sphincter


instrument inserted a short distance into the anal canal, procedures using anoscope are reported with endoscopy codes 46600-46615

destruction of anal lesions

methods include chemical, eletrodessication, cryosurgery, laser surger and surgical excision


(piles) from an inflammation of the venous plexuses (congregation of vessels) around the anus and may be inside or outside of anal canal. classifed into four degrees

The dentate line is the line where the anal mucosal lining meets the skin (mucocutaneous junction or anal verge).

used to measure degree of hemorrhoid

Liver biopsy

may be performed percutaneously using imaging guidance that is reported separtely, if biopsy is performed at the time of a more major surgery, reported with add-on code 47001.

wedge biopsy

involves removal through incision of a small fan-shaped section of tissue for examination

liver transplant

each component of the transplant is reported separately

backbench work

special preparation of the graft before tranplntation

biliary tract

gallbladder connected the liver and small intestine by biliary tract


incisional procedure of gallbladder


exploration of the tract to determine cause of obstruction and may include removal of calculus or drainage of bile from tract


incision into the biliary tract


formation of a stoma between abdominal wall and gallbladder

biliary tract stents


laparoscopic cholecystectomy

placement of ports through the abdominal wall into the laparoscope and instrumentation are inserted to remove the gallbladder

When procedure begun but converted to another technique during same operative session

code only the successful approach


inflamed pancreas


total or partial pancreas removalstranglated


hernia cutting of blood supply

incarcerated hernia

cannot be returned to abdominal cavity


surgical repair of hernia

1) exploratory laparotomy with cholecystectomy

CPT code

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