MP 10.01.08 Laparoscopic, Endoscopic, Thoracoscopic Surgery Medical Policy Section Administrative Issue 12:2013 Original Policy Date 12:2013 Last Review Status/Date 12:2013 Return to Medical Policy Index Disclaimer Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. Description As used in this policy, endoscopic surgery is a general term describing a form of minimally invasive surgery in which access to a body cavity is achieved through several small percutaneous incisions. The surgery is performed using specialized instrumentation inserted through the incisions (i.e., trocar sites) and guided by the use of a fiberoptic endoscope that provides visualization of the body cavity on a video screen. In endoscopic surgery, the surgeon does not have direct visualization of the surgical field, and thus endoscopic techniques require specialized skills compared to the corresponding open surgical techniques. Endoscopic surgery may also refer to the use of a fiberoptic endoscope inserted through a body orifice into a body cavity such as the gastrointestinal tract, bronchi, uterus, or bladder. These applications of endoscopic surgery are not addressed by this policy. While endoscopic surgery is a general term, laparoscopic, thoracoscopic, and arthroscopic surgery describe endoscopic surgery within the abdomen, thoracic cavity, and joint spaces, respectively. In most instances, the endoscopic technique attempts to duplicate the same surgical techniques and principles as the corresponding open techniques, with the only difference being surgical access. For example, laparoscopic cholecystectomy, performed since 1990, espouses the same surgical principles as open cholecystectomy. The advantages of endoscopic surgery include shorter hospital stays and more rapid recovery such that the patient may be able to return to work promptly. Disadvantages include a longer operative time, particularly if the surgeon is early on the learning curve for these new techniques.
Some endoscopic approaches entail novel surgical principles, and thus raise issues of safety and effectiveness apart from the safety and effectiveness of the endoscopic approach itself. For example, open herniorrhaphy is typically done from an inguinal approach, while laparoscopic herniorrhaphy involves a unique abdominal approach. In other procedures, the surgical dissection can be done entirely with endoscopic guidance, but the resulting surgical specimen may be too large to remove through the small trocar incision. Novel approaches have been devised to overcome this limitation. For example, in laparoscopic splenectomy or nephrectomy, the resected specimens are placed into a bag intra-abdominally, morcellated, and then removed through a small muscle-splitting incision. Similarly, laparoscopic colectomy specimens can be removed through either a muscle-splitting incision, or transanally for distal specimens. Surgeries can combine an open and laparoscopic approach; for example laparoscopic-assisted vaginal hysterectomy may entail a laparoscopic surgical dissection, with removal of the specimen through a vaginal incision similar to an open vaginal hysterectomy. In most instances it is assumed that an endoscopic approach is a direct substitution for the corresponding open approach. However, the decreased morbidity of endoscopic surgeries in general may broaden the patient selection criteria for certain surgeries. For example, open gastric fundoplication is typically limited to those patients who have failed medical management with H-2 blockers and antimotility agents. Now, however, laparoscopic fundoplication may be considered an alternative to lifelong medical management. Similarly, open plantar fasciotomy is typically reserved for those symptomatic patients who have failed a prolonged attempt at conservative management. The decreased morbidity of an endoscopic approach may prompt a shortened period of conservative management. Endoscopic, laparoscopic, and thoracoscopic CPT codes for which there are CPT codes for the corresponding open surgical procedure are summarized below. Not included are those CPT codes describing endoscopic diagnostic procedures and those describing arthroscopic procedures, with the exception of endoscopic carpal tunnel release and endoscopic plantar fasciotomy. The following table correlates the laparoscopic CPT code with the corresponding open procedure. Laparoscopic Surgical (i.e., non-diagnostic) CPT Codes Laparoscopic CPT Codes CPT Code Corresponding Open Procedure 38120: splenectomy 38100: splenectomy 38129: unlisted laparoscopy procedure, spleen 38570: laparoscopic retroperitoneal lymph node sampling 38571: laparoscopic bilateral total pelvic lymphadenectomy 38572: laparoscopic bilateral total pelvic lymphadenectomy with peri-aortic lymph node sampling 38589: Unlisted laparoscopy procedure, 38780: retroperitoneal transabdominal lymphadenectomy 38770: pelvic lymphadenectomy 38780: retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal nodes
lymphatic system 43280: laparoscopic esophagogastric fundoplication 43279: laparoscopic esophagomyotomy with fundoplasty (Heller myotomy) 43289: Unlisted laparoscopy procedure, esophagus 43651-52: laparoscopic transsection of vagal nerves, truncal or selective, respectively 43653: laparoscopic gastrostomy, without construction of gastric tube 43324: esophagogastric fundoplasty 43330: Esophagomyotomy (Heller type); abdominal approach 43640-43641: truncal or highly selective vagotomy, respectively No identical CPT code; 43500 (gastrostomy; with exploration may be the closest) 43653: laparoscopic gastrostomy, temporary 43830: gastrostomy, temporary 43659: Unlisted laparoscopy procedure, stomach 44200: laparoscopic enterolysis 44005: enterolysis 44201: laparoscopic jejunostomy 44310: ileostomy or jejunostomy, non-tube 44202: laparoscopic intestinal resection, with anastomosis 44203: each additional small intestine resection 44140-44121: Colectomy partial, with anastomosis or colostomy, respectively 44204: laparoscopic colectomy, partial, with anastomosis 44205: laparoscopic colectomy, partial, with removal of terminal ileum with ileocolostomy 44206: laparoscopic colectomy, Hartmann-type procedure 44207: laparoscopic colectomy, low pelvic anastomosis 44208: laparoscopic colectomy, partial, with coloproctostomy 44210: laparoscopic colectomy, total abdominal, without proctectomy 44211: laparoscopic colectomy, total abdominal, with proctectomy with ileoanal anastomosis, creation of ileal reservoir, with loop ileostomy, with or without rectal mucosectomy 44212: laparoscopic colectomy, total abdominal, with proctectomy with ileoanal anastomosis, creation of ileal reservoir, with 44160: Colectomy, partial, with removal of terminal ileum with ileocolostomy 44143: Colectomy, partial, Hartmann-type procedure 44145: Colectomy, with low pelvic anastomosis 44146: Colectomy, partial, with coloproctostomy 44150: Colectomy, total abdominal, without proctectomy 44152-44153: Colectomy, total abdominal, with proctectomy with ileoanal anastomosis, creation of ileal reservoir, with loop ileostomy, with or without rectal mucosectomy 44155: Colectomy, total abdominal, with proctectomy with ileoanal anastomosis, creation of ileal reservoir, with loop ileostomy,
loop ileostomy, with or without rectal mucosectomy 44238: Unlisted laparoscopy procedure, intestine (except rectum) 44239 Unlisted laparoscopy procedure, rectum 44970: laparoscopy, surgical, appendectomy 44979: Unlisted laparoscopy procedure, appendix 47370-71: laparoscopy, surgical ablation of one or more liver tumor(s) with radiofrequency or cryosurgery, respectively* with or without rectal mucosectomy 44950-60: appendectomy, as separate procedure, or for ruptured appendix 47380-82: Ablation open, of one or more liver tumors, radiofrequency or crysurgery, respectively* 47382: Ablation, one or more liver tumors, percutaneous, radiofrequency* *Radiofrequency and cryosurgical ablation of liver tumors considered investigational, when performed via an open procedure, laparoscopically or percutaneously. See policy No. 7.01.75. 47500: injection procedure for percutaneous transhepatic cholangiography 47560-61: laparoscopy, surgical; with guided transhepatic cholangiography, without or with biopsy, respectively 74300: cholangiography; intraoperative with radiological supervision and interpretation 47562-64: laparoscopic cholecystectomy; any method, with cholangiography, or exploration of the common duct, respectively 74320: cholangiography, percutaneous, transhepatic, radiological supervision and interpretation 47600-47610: cholecystectomy with cholangiography or exploration of the common bile duct, respectively 47570: laparoscopic cholecystoenterostomy 47720: cholecystoenterostomy 47579: unlisted laparoscopy procedure, biliary system 49320: laparoscopy, abdomen, peritoneum and omentum, diagnostic 49321: laparoscopic biopsy of biliary system 49322: laparoscopic aspiration of cavity or cyst 49000: exploratory laparotomy, exploratory celiotomy variety of CPT codes corresponding to biopsy or aspiration of specific organs or tissue various CPT codes describing cysts in various locations, i.e., pancreas (48510), liver (47010), ovary (58805) 49323: with drainage of lymphocele to 49062; drainage of extraperitoneal lymphocele
peritoneal cavity to 49329; Unlisted laparoscopic procedure, abdomen, peritoneum and omentum 49652: Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible (new 2009) 49653: ; incarcerated or strangulated (new 2009) 49654: Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible (new 2009) 49655: ; incarcerated or strangulated (new 2009) 49656: Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible (new 2009) 49657: ; incarcerated or strangulated (new 2009) 49650-51: laparoscopic repair of initial, recurrent inguinal hernia, respectively peritoneal cavity, open 49568: Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection 49495-49525: CPT codes vary according to patient age, initial, recurrent, or incarcerated hernia 49659: Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy No exact corresponding open procedure, but 50541: laparoscopic ablation of renal cysts CPT code 50280 (Excision or unroofing of cysts of kidney) 50542: laparoscopic ablation of renal mass 50220-50240 nephrectomy code range lesion 50543: laparoscopic partial nephrectomy 50240: nephrectomy, partial 50544: laparoscopic pyeloplasty 50400; pyeloplasty 50545: laparoscopic radical nephrectomy 50230:nephrectomy, radical 50546: laparoscopic nephrectomy 50220; nephrectomy 50547: donor nephrectomy from living donor 50300; donor nephrectomy 50548: laparoscopically assisted 50220; nephrectomy nephroureterectomy 50549: unlisted laparoscopic produce, renal
50945: laparoscopy, surgical ureterolithotomy 50947: laparoscopic ureteroneocystostomy with csytoscopy and ureteral stent placement 50948: laparoscopic ureteroneocystostomy without cystoscopy and stent placement 50949: Unlisted laparoscopy procedure, ureter 51990: laparoscopic urethral suspension for stress incontinence 51992: laparoscopic sling operation for stress incontinence 50610-50630; ureterolithotomy, various locations There is no CPT code that describes open ureteroneocystostomy specifically in conjunction with stent placement 50780: ureteroneocystostomy 51840: anterior vesicourethropexy, or urethropexy; simple 57288; sling operation for stress incontinence 54690: laparoscopic orchiectomy 54520: simple orchiectomy 54692: laparoscopic orchiopexy for intraabdominal testis 54640-54650; orchiopexy 54699: unlisted laparoscopy procedure, testis 55550: laparoscopic ligation of spermatic veins 55530-55535: excision of varicocele for varicocele 55559: unlisted laparoscopy procedure; spermatic cord 58545-46: Laparoscopy, surgical, myomectomy, 58140, 58146: Surgical myomectomy, excision, less than or greater than 250 gm, abdominal approach, less than or greater than respectively 250 gm, respectively 58550-52: laparoscopic vaginal hysterectomy for uterus 250 gm or less with or without removal of tube and/or ovary (addressed in policy 7.01.57) 58260-58262: Vaginal hysterectomy with or without removal of tube(s) and ovary(s) 58553-53: laparoscopic vaginal hysterectomy for uterus weighing greater than 250 gm with or without removal of tube and/or ovary (addressed in policy 7.01.57) 55866: laparoscopy, surgical prostatectomy, retropubic radical 58578: unlisted laparoscopy procedure, uterus 55840: prostatectomy, retropubic radical 58740: lysis of adhesion 58660: laparoscopic lysis of adhesion 58661: laparoscopic removal of adnexal structure (partial or total oophorectomy and/or salpingectomy) 58940: total or partial oophorectomy
58700: complete or partial salpingectomy 58662: laparoscopic fulguration or excision of 49200-49201: excision or destruction by any lesions of the ovary, pelvic viscera, or peritoneal method of intra-abdominal or retroperitoneal surface by any method tumors or cysts or endometriomas 58600-58615: ligation or transsection of 58670-71: laparoscopic fulguration of oviducts fallopian tubes 58673: laparoscopic salpingostomy 58770: salpingostomy 58672: laparoscopic fimbrioplasty 58760: fimbrioplasty 58679: unlisted laparoscopy procedure, oviduct, ovary 59898: unlisted laparoscopy procedure, maternity care and delivery 60650: laparoscopic adrenalectomy 60540: adrenalectomy 60659: unlisted laparoscopic procedure, endocrine system The following table summarizes CPT codes for endoscopic orthopedic procedures and thoracoscopic procedures with the CPT code for the corresponding open procedure. CPT Code Corresponding Open Endoscopic/Thoracoscopic CPT Codes Procedure Endoscopic Orthopedic Procedures 64721: neuroplasty of median nerve at 29848: arthroscopic release of carpal tunnel ligament carpal tunnel 29893: endoscopic plantar fasciotomy 28008: fasciotomy, foot and/or toe Thoracoscopic Procedures 32601-32606: Thoracoscopy, diagnostic, with and without biopsy of a variety of structures 32035: Thoractomy, limited for biopsy of lung or pleura 32650: pleurodesis 32005: chemical pleurodesis 32651-2: partial or total pleural decortication, respectively 32653: removal of intrapleural foreign body 32320: decortication and parietal pleurectomy 32150 removal of intrapleural foreign body 32654: control of traumatic hemorrhage 32110: control of traumatic hemorrhage 32655: excision-plication of bullae 32141: excision-plication of bullae 32656: parietal pleurectomy 32310: parietal pleurectomy 32657: wedge resection 32500: wedge resection 32658: removal of clot or foreign body from pericardial sac 32659: creation of pericardial window, or partial resection of pericardial sac for drainage 32660: total pericardiectomy 33020: pericardiotomy for removal of clot or foreign body 33025: creation of pericardial window or partial resection for drainage 33030: subtotal or complete pericardiectomy 32661: excision of pericardial cyst, tumor, mass 33050: excision of pericardial cyst or
tumor 32662: excision of mediastinal mass 39220: excision of mediastinal tumor 32663: lobectomy, total or segmental 324800-32484: describes lobectomy procedures 32664: thoracic sympathectomy 64809: sympathectomy, thoracolumbar 32665: esophagomyotomy 43331: esophagomyotomy; thoracic approach Policy The endoscopic procedures listed above may be considered medically necessary as an alternative to the corresponding open surgical procedures with the exception of laparoscopic radiofrequency or cryosurgical ablation of liver tumors. These procedures are considered separately in policy No. 7.01.75. Policy Guidelines A listing of patient selection criteria for each laparoscopic/thoracoscopic/arthroscopic/endoscopic procedure is beyond the scope of this policy. However, in general, candidates for such an endoscopic procedure should meet patient selection criteria for the corresponding open procedure; endoscopic procedures should not be considered an alternative to appropriate medical management. This may be of particular concern in laparoscopic fundoplication and endoscopic plantar fasciotomy when proposed before an adequate trial of medical management. Benefit Application Physicians may request an increased level of reimbursement compared to the corresponding open procedure, based on the increased operating room (OR) time and the additional training and expertise required to perform endoscopic surgery. However, the increased OR time may be compensated for by the decreased hospitalization and follow-up period. Each plan should consider whether to treat reimbursement of endoscopic, laparoscopic, or arthroscopic procedures differently than the corresponding open procedures.
Rationale American Medical Association. Common Procedural Terminology Year 2002 Codes Number Description CPT codes See Description section, above ICD-9 Procedure 04.43 Release of carpal tunnel 05.29 Other sympathectomy and ganglionectomy 07.22 07.30 Adrenalectomy code range 32.21 Plication of emphysematous bleb 32.29 Other local excision o r destruction of lesion or tissue of lung 32.3 Segmental resection of lung 32.4 Lobectomy of lung 33.39 Other surgical collapse of lung 34.3 Excision or destruction of lesion or tissue of mediastinum 34.4 Excision or destruction of lesion of chest wall 34.09 Other incision of pleura 34.51 Decortication of lung 34.59 Other excision of pleura 34.6 Scarification of pleura 34.92 Injection into thoracic cavity 37.12 Other local excision or destruction of lesion or tissue of lung 37.31 Pericardiectomy 37.33 Excision or destruction of other lesion or tissue of heart 40.11 Biopsy of lymphatic structure 40.3 Regional lymph node excision 41.43 Partial splenectomy 41.5 Total splenectomy 42.7 Esophagomyotomy 43.19 Temporary gastrostomy 44.01 44.03 Vagotomy, code range 44.66 Other procedures for creation of esophagogastric sphincteric competence (includes fundoplication) 45.61 45.63 Other excision of small intestine, code range
45.71 45.79 Partial excision of large intestine, code range 45.8 Total intra-abdominal colectomy 46.01 46.04 Exteriorization of intestine, code range 46.31 46.39 Enterostomy, code range 47.01 Laparoscopic appendectomy 51.23 Laparoscopic cholecystectomy 51.24 Laparoscopic partial cholecystectomy 51.32 Anastomosis of gallbladder to intestine 51.51 Exploration of common bile duct 53.00 Unilateral repair of inguinal hernia, not otherwise specified 53.01 Unilateral repair of direct inguinal hernia 53.10 Bilateral repair of inguinal hernia 54.21 Laparoscopy 54.23 Biopsy of peritoneum 54.24 Closed biopsy of intra-abdominal mass 54.4 Excision or destruction of peritoneal tissue 54.51 Laparoscopic lysis of peritoneal adhesions (includes laparoscopic enterolysis) 59.03 Laparoscopic lysis of perirenal or periureteral tissue 59.12 Laparoscopic lysis of perivesical adhesions 62.3 Unilateral orchiectomy 62.41 62.42 Removal of testes, code range 63.1 Excision of variocele and hydrocele of spermatic cord 65.13 Laparoscopic biopsy of ovary 65.24 Laparoscopic wedge resection of ovary 65.25 Other laparoscopic local excision or destruction of ovary (includes partial oophorectomy) 65.31 Laparoscopic unilateral oophorectomy 65.41 Laparoscopic unilateral salpingooophorectomy 65.53 Laparoscopic removal of both ovaries at same operative episode 65.54 Laparoscopic removal of remaining ovary 65.63 Laparoscopic removal of both ovaries and tubes at same operative episode 65.64 Laparoscopic removal of remaining ovary and tube 65.76 Laparoscopic salpingo-oophoroplasty
ICD-9 Diagnosis HCPCS Type of Service Place of Service 65.81 Laparoscopic lysis of adhesions of ovary and fallopian tube 66.02 Salpingostomy 66.21 66.22 Bilateral endoscopic ligation and crushing, or division of fallopian tubes, code range 66.79 Other repair of fallopian tubes 68.15 Closed biopsy of uterine ligaments 68.16 Closed biopsy of uterus 68.29 Other excision or destruction of lesion of uterus 68.51 Laparoscopically assisted vaginal hysterectomy (LAVH) 83.14 Fasciotomy 87.53 Intraoperative cholangiogram Refer to policy for corresponding open procedure No codes Surgery Inpatient Index Endoscopic Surgery, General Laparoscopic Surgery, General Thoracoscopic Surgery, General