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Ivor Lewis Esophagectomy and Two Surgeons

image of transthoracic esophagectomy (TTE) showing the location of the esophagus and the stomach.
A TTE procedure (Ivor Lewis esophagectomy) is mainly used to treat esophageal cancer.

The Coding Challenge

Question: A patient undergoes an Ivor Lewis esophagectomy with a thoracotomy. Dr. Blue, a thoracic surgeon, performs the thoracic approach and thoracic procedures, and Dr. Green, a general surgeon, performs the abdominal procedures. How would Dr. Blue report for his part of the procedure?

A. 43122-59
B. 43287-80
C. 43117-62
D. 43118-81

Answer:

C. 43117-62

What is an Ivor Lewis Esophagectomy?

An Ivor Lewis esophagectomy, otherwise known as a transthoracic esophagectomy (TTE), is a procedure performed to remove part of the esophagus. It is mainly used to treat esophageal cancer involving the upper two-thirds of the esophagus. The transthoracic approach (thoracotomy) involves making an incision in the thoracic cavity or chest wall to expose the esophagus. 

According to Moffitt Cancer Center, small incisions are made in the chest, and one incision is made in the abdomen. The cancerous part of the esophagus and surrounding lymph nodes are removed, along with a small amount of healthy tissue above and below the tumor. The stomach is then pulled up into the chest and joined with the remaining section of the esophagus.

The esophagus is the long, muscular tube that connects the throat (pharynx) with the stomach. It runs behind the windpipe (trachea) and heart and in front of the spine.

CPT Coding – Locate and Verify

Esophagectomy

In the CPT Alphabetic Index, look up Esophagectomy. It refers us to 43107-43124 and 43286-43288. These are digestive system surgery codes. When we go to these codes in the Tabular, we can see that codes 43107-43124 are listed under Excision Procedures on the Esophagus. Codes 43286-43288 are listed under Laparoscopic Procedures on the Esophagus.

The documentation states an Ivor Lewis esophagectomy with a thoracotomy was performed. A thoracotomy is a surgical incision into the chest, which means it is an open procedure and should probably be assigned a code from 43107-43124. I say probably because that is not alwas the case. Sometimes a laparoscopic procedure contains an open element, which I explain more about at the bottom of this post under “Additional Information.”

In the Tabular, codes 43107-43124 are described as:

  • 43107, Total or near total esophagectomy, without thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty (transhiatal)
  • 43108, Total or near total esophagectomy, without thoracotomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es)
  • 43112, Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty (i.e., McKeown esophagectomy or tri-incisional esophagectomy)
  • 43113, Total or near total esophagectomy, with thoracotomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es)
  • 43116, Partial esophagectomy, cervical, with free intestinal graft, including microvascular anastomosis, obtaining the graft and intestinal reconstruction
  • 43117, Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with thoracic esophagogastrostomy, with or without pyloroplasty (Ivor Lewis)
  • 43118, Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es)
  • 43121, Partial esophagectomy, distal two-thirds, with thoracotomy only, with or without proximal gastrectomy, with thoracic esophagogastrostomy, with or without pyloroplasty
  • 43122, Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; with esophagogastrostomy, with or without pyloroplasty
  • 43123, Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es)
  • 43124, Total or partial esophagectomy, without reconstruction (any approach), with cervical esophagostomy

Our correct code is:

43117, Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with thoracic esophagogastrostomy, with or without pyloroplasty (Ivor Lewis)

Note: A proximal gastrectomy and pyloroplasty may or may not be included in this procedure to report code 43117. A proximal gastrectomy is the removal of the upper third to one-half of the stomach and the distal portion of the esophagus. A pyloroplasty is the surgical widening of the pylorus, the lower part of the stomach.

Now we need a modifier.  

Modifier – 2 Surgeons

The documentation states that two surgeons worked together as co-surgeons in this one procedure. Each surgeon performed distinct parts of the procedure. A thoracic surgeon (Dr. Blue) performed the thoracic approach and procedures, and a general surgeon (Dr. Green) performed the abdominal procedures. 

According to CPT, Modifier 62: Two Surgeons, is defined as:

“When 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added.

Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.”

Therefore, modifier -62 needs to be appended to code 43117 to show that Dr. Blue carried out a distinct part of this procedure, making the correct code 43117-62. 

Dr. Blue should also document in his operative report the individual work he/she performed in the procedure and attach a copy of the operative report to the insurance claim for reimbursement.   

Although we are not being asked here to report for Dr. Green, Dr. Green would also need to report 43117-62 for his/her part of the work, document his part of the procedure, and attach a copy to the insurance claim.

Incorrect Answers

A, B, and D are incorrect.

A. 43122-59. 43122 refers to Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; with esophagogastrostomy, with or without pyloroplasty. This is a different procedure. Modifier 59 is incorrect. It is used for a distinct procedure service and is used to identify services not typically reported together but are appropriate under the reported circumstances.

B. 43287-80. 43287 refers to 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 (i.e., laparoscopic thoracoscopic esophagectomy, Ivor Lewis esophagectomy).

Code 43287 describes a laparoscopic procedure, not an open procedure. Even though “Ivor Lewis esophagectomy” is included in the code description, it is a laparoscopic approach rather than an open (thoracotomy) approach. Also, modifier 80 is incorrect; this modifier is used when surgical surgeon assistant services are needed.

Make sure to look in the documentation for such terms as thoracotomy and laparoscopic (minimally invasive) to help distinguish between 43117 and 43287.

D. 43118-81. 43118 refers to Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es). This is a different procedure than what took place and lacks the appropriate modifier. Modifier 81 is used when another surgeon is called in to assist for a limited amount of time.

Additional Information

Pay close attention to the code descriptions for esophagectomy. Don’t assume because the documentation uses the term “open” in the procedure that it must be reported with codes 43107-43124 (Excision Procedures on the Esophagus) rather than with codes from 43286-43288 ( Laparoscopic Procedures on the Esophagus). That is not necessarily the case.

Why? Because, although codes 43286-43288 describe laparoscopic (minimally invasive/keyhole) procedures, codes 43286 and 43288 also contain an open element (“… with open cervical pharyngogastrostomy or esophagogastrostomy…”).

Their full descriptions are:

  • 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 (i.e., laparoscopic transhiatal 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 (i.e., thoracoscopic, laparoscopic and cervical incision esophagectomy, McKeown esophagectomy, tri-incisional esophagectomy)

** This post was reviewed and revised on January 6, 2022. **


“The best preparation for tomorrow is doing your best today.”  – H. Jackson Brown, Jr.


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