General Surgery Coding Alert

Look for op note details to choose the right code.

If you've been turning to the same unlisted code every time your surgeon performed a laparoscopic or thoracoscopic esophagectomy, your coding choices just expanded greatly and got far more specific.

That's because CPT^® 2018 adds three new codes to describe esophagectomy using thoracoscopic and/or laparoscopic esophageal mobilization, with distinct codes describing different anatomic approaches.

Grasp Esophagectomy Complexity

Used primarily to treat esophageal cancer, traditional open esophagectomy procedures are typically very complex, invasive surgeries that use various incisions and approaches. For instance, the Ivor Lewis procedure involves two primary incisions - a laparotomy to mobilize the stomach, and a right thoracotomy to resect the esophagus.

Surgeons may also perform a transhiatal esophagectomy, or a McKeown procedure, also called "tri-incisional" esophagectomy. Like the Ivor Lewis, these surgeries use a laparotomy to mobilize the stomach, but vary by also including a neck incision.

Laparoscopic: The minimally invasive esophagectomy procedures grew out of the various open approaches, essentially modifying a specific operation (such as Ivor Lewis) to use laparoscopes for the abdominal portion or thorascopes for the transhiatal or transthoracic part of the surgery.

Mix and match: When you go to select an esophagectomy code, whether open or minimally invasive, you'll need to pay attention to the op note narrative of the various aspects of the surgery and choose the code that accurately describes the surgeon's work.

Greet 3 New Esophagectomy Codes

Prior to CPT^® 2018, you've had no choice but to report a minimally-invasive esophagectomy procedure that uses a laparoscopic and/or thorascopic approach as 43499 (Unlisted procedure, esophagus). Although CPT^® provides many specific codes to describe open partial or total esophagectomy procedures (43107-43124), none of the codes adequately describes a laparoscopic esophagectomy.

New options: Beginning Jan. 1, you'll need to choose between the following new codes when you face an op report that describes a laparoscopic and/or thoracoscopic esophagectomy:

• 43286 (Esophagectomy, total or near total, with laparoscopic mobilization of the abdominal and mediastinal esophagus and proximal gastrectomy, with laparoscopic pyloric drainage procedure if performed, with open cervical pharyngogastrostomy or esophagogastrostomy (ie, laparoscopic transhiatal esophagectomy))
• 43287 (Esophagectomy, distal two-thirds, with laparoscopic mobilization of the abdominal and lower mediastinal esophagus and proximal gastrectomy, with laparoscopic pyloric drainage procedure if performed, with separate thoracoscopic mobilization of the middle and upper mediastinal esophagus and thoracic esophagogastrostomy (ie, laparoscopic thoracoscopic esophagectomy, Ivor Lewis esophagectomy))
• 43288 (Esophagectomy, total or near total, with thoracoscopic mobilization of the upper, middle, and lower mediastinal esophagus, with separate laparoscopic proximal gastrectomy, with laparoscopic pyloric drainage procedure if performed, with open cervical pharyngogastrostomy or esophagogastrostomy (ie, thoracoscopic, laparoscopic and cervical incision esophagectomy, McKeown esophagectomy, tri-incisional esophagectomy)).

Helpful: "For those coders in groups where esophagectomy is done, these nuances are helpful since surgeons may use words like 'McKeown' in their reports, so coders could more easily recognize what procedure was done," says Glenn Littenberg MD, a physician in Pasadena, Calif.

Look for Revised Code, Too

As part of the effort to clarify, specify, and expand esophagectomy coding options, CPT^® 2018 also revises an existing esophagectomy code, as follows:

• Old way: 43112 (Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty)
• New way: 43112 (Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty (ie, McKeown esophagectomy or tri-incisional esophagectomy))

Again, by adding the nomenclature you might see in an op report, such as "McKeown," this change adds clarity and specificity to esophagectomy coding.