Excise Bad Whipple Procedure Coding
By Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS, CCS-P
Anatomy and Terminology to Know
The most common Whipple procedure is an en bloc removal of:
- Distal segment (antrum) of the stomach
- First and second portions of the duodenum
- Head of the pancreas
- Common bile duct
Separately, excisions may be documented as antrectomy (removal of the distal half of the stomach); cholecystectomy (removal of the gallbladder and cystic duct); choledochectomy (removal of the common bile duct); subtotal or partial pancreatectomy (removal of the head of the pancreas); duodenectomy or enterectomy (removal of the duodenum and/or proximal jejunum); and lymphadenectomy (removal of lymph nodes).
The Whipple also requires reconstructions—pancreaticojejunostomy (attaching the pancreas to the jejunum), hepaticojejunostomy (attaching the hepatic duct to the jejunum), and gastrojejunostomy (attaching the stomach to the jejunum)—to repair the gastrointestinal tract and allow food to pass through.
Coding Whipple Procedures
There are four CPT® codes for Whipple procedures:
4815 Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); with pancreatojejunostomy
48152 without pancreatojejunostomy
48153 Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); with pancreatojejunostomy
48154 without pancreatojejunostomy
Codes 48150 and 48152 describe the standard Whipple procedures, with partial pancreatectomy (subtotal), total removal of the duodenum, partial removal of the stomach, and anastomosis of the bile duct to the intestines and the stomach to the jejunum. Code 48150 includes anastomosis of the pancreatic ducts with the jejunum (pancreatojejunostomy)—48152 does not include this repair.
Codes 48153 and 48154 describe the same procedures, by pylorus-sparing technique. The pylorus-sparing pancreaticoduodenectomy is the procedure performed more often. Its main advantage is that the pylorus (and normal gastric emptying) is preserved. It can be performed when the tumor does not involve the stomach, and the lymph nodes along the gastric curvatures are not enlarged.
This is a sample operative note, with explanatory comments to help you interpret and code Whipple procedures:
PREOPERATIVE DIAGNOSIS: Pancreatic adenocarcinoma (1)
POSTOPERATIVE DIAGNOSIS: Pancreatic adenocarcinoma (2)
OPERATION: Pylorus preserving Whipple (3)
ANESTHESIA: General plus epidural
INDICATIONS: 67-year-old man with adenocarcinoma of the pancreatic head
FINDINGS: There was no suggestion of surface metastases on the liver, peritoneal surfaces, or omentum. We obtained peritoneal washings in the right upper quadrant, sent for permanent pathology only. The colon, entire small bowel, appendix, both kidneys, liver, and stomach were all normal. We then performed a Kocher maneuver with no evidence of tumor adherence to the IVC. The common hepatic artery was likewise free of involvement, and there was no evidence of disease coming out of the root of the mesentery through the gastrocolic ligament.
PROCEDURE: After general anesthesia, sterile prep and drape, and IV antibiotics, we made an upper midline incision. The abdomen was fully explored with findings as above. We then took down the gallbladder (4) and kept this in continuity with the primary specimen. We dissected along the portal artery and identified, divided, and suture ligated the gastroduodenal artery. We then surrounded the common bile duct above the entry of the cystic duct and palpated a stent that had been placed previously. We were able to divide just above the stent and placed a bulldog clamp on the liver side. The lower side was suture ligated after verification that the stent was in the specimen side. The anterior surface of the portal vein had no adhesions. We developed a plane on the inferior border of the pancreas along the vein, and there were also no adhesions there. We then divided the proximal duodenum with a GIA stapler, at least 3 cm distal to the pylorus (5), preserving the incoming vessels, and the intact stomach and proximal duodenum were placed into the left upper quadrant. We then divided the proximal jejunum and took down the mesentery to pass the proximal jejunum and duodenum (6) behind the mesenteric vessels to the right side of the abdomen. The retroperitoneal defect was closed with figure-of-eight 3-0 silk sutures. We placed four stay sutures, two in the superior, two in the inferior aspect of the pancreatic neck, and after freeing up the entire posterior surface of the neck, the pancreas was divided with a combination of cautery for the periphery and a sharp dissection across the dilated pancreatic duct (7). There was minimal bleeding. A pancreatic margin was taken from the specimen side and a frozen section revealed no evidence of carcinoma. We then took down all of the branches from the superior mesenteric and portal venous system as well as along the right side of the SMA. There was no tumor involvement in either artery or vein. An en bloc (8) peripancreatic lymphadenectomy (9) was performed with this. Any visible or suspected lymphatics and lacteals were clipped or tied. The entire specimen was removed and oriented for the pathologist. The bile duct margin came back with atypical cells. This was in the setting of previous radiation and stent placement. We still took an additional just-under 1 cm bile duct margin and sent this true margin for permanent pathology only (10). This represented approximately 2 cm above the entry of the cystic duct site, and we had a low clinical suspicion for this area. We brought the jejunal limb for reconstruction through the right side of the mesocolon and oversewed the end of the staple line with a running Prolene suture. We performed a tension-free two-layer end-to-side pancreaticojejunostomy (11) with an outer layer of 3-0 silk interrupted sutures and an inner layer of duct to mucosa 5-0 Maxon sutures. The final and fifth suture was placed anteriorly and included a short segment of 5-French infant feeding tube as an indwelling stent. An outer layer of 3-0 silk sutures was placed. We then performed a tension-free end-to-side choledochojejunostomy (12) using a single layer of 4-0 Maxon sutures tied on the outside. The common duct was quite large, and this was a wide open anastomosis with no evidence of leak or tension. Using the same limb just downstream but still above the mesocolon, we performed an end-to-side duodenojejunostomy (13) with a single layer of interrupted silk modified Gambee sutures. This was approximately 12-15 cm below the bile duct anastomosis 12 to 15 cm. We secured the jejunal limb to the mesocolon and made sure there was no twisting of the mesentery and there was good blood supply to this limb and no tension. After a satisfactory sponge, needle, and instrument count, we placed two round 15 drains, one in the right upper quadrant near the biliary anastomosis and one in the left upper quadrant near the pancreatic anastomosis and closed the abdomen with running No. 1 looped Maxon suture on fascia and skin staples. The patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: 500 mL
FLUIDS: 5000 mL crystalloid, 500 mL albumin
DRAINS: Blake times 2
1. Peritoneal fluid for permanent pathology.
2. Pancreatic margin.
3. Head of pancreas, duodenum, and gallbladder.
4. New bile duct margin.
1. These procedures usually are performed for patients with pancreatic cancer. Less frequently, they will be performed for patients with massive abdominal traumas.
2. This patient already has biopsy-proven cancer so there is no need to wait for biopsy results before choosing the right diagnosis code, 157.0 Malignant neoplasm of head of pancreas.
3. If you’re unfamiliar with a procedure described with an eponym (named after the surgeon who created the procedure), you can look up the eponym in the index. This should point you to the right part of the book to find a code.
4. Cholecystectomy cannot be billed separately when performed with a Whipple procedure.
5. Note that the pylorus was not removed. Although this was indicated above, it is critical to find the actual documentation of this to assign the correct code.
6. Code 48153 includes a “near-total” duodenectomy.
7. Code 48153 also includes a subtotal pancreatectomy, with the proximal or tail of the pancreas preserved.
8. The term en bloc refers to resection of a whole block of tissue.
9. All lymph nodes in the area of the pancreas were removed.
10. This cannot be coded separately when more tissue is taken to obtain a clear margin during the same resection.
11. Note: This is defining code 48153, as opposed to 48154.
12. This is another key component of the reconstruction; it doesn’t matter if it is done end-to-side or end-to-end.
13. For the pylorus-sparing procedure, the remnant of the duodenum is anastomosed to the jejunum rather than to the stomach
Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS, CCS-P, is compliance education manager for a large university practice group. She is the long-time consulting editor for General Surgery Coding Alert newsletter and has presented at five AAPC national meetings.