How To Use CPT Code 43331

CPT 43331 describes a surgical procedure known as esophagomyotomy, specifically performed through a thoracic approach. This article will provide an overview of CPT code 43331, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 43331?

CPT 43331 is a code used to describe a surgical procedure called esophagomyotomy. This procedure involves making an incision in the muscles of the lower esophagus and upper stomach through a thoracic approach. The purpose of this surgery is to create a flap that is then sutured back to the esophagus, allowing the esophageal sphincter to relax properly and improving the passage of food into the stomach.

2. Official Description

The official description of CPT code 43331 is: ‘Esophagomyotomy (Heller type); thoracic approach.’ This code is specifically used for the surgical repair of the esophagus through a chest incision, where the provider incises the muscles of the lower esophagus and upper stomach to create a flap that is then sutured back to the esophagus.

3. Procedure

1. The provider begins by making an incision in the chest to access the thorax.
2. Once inside the thorax, the provider identifies the esophagus and stomach.
3. Using a scalpel, the provider carefully incises the superficial layers of the esophagus, lower esophageal sphincter, and stomach, leaving the inner layer intact.
4. This incision creates a flap that the provider wraps around the distal esophagus, causing the sphincter to close when the stomach contracts, thus limiting reflux.
5. The provider ensures hemostasis, or the stopping of bleeding from incisions and suture lines.
6. Finally, the provider closes the abdominal incision in layers.

4. Qualifying circumstances

CPT 43331 is typically performed as a surgical treatment for a condition called esophageal achalasia. This condition is characterized by the failure of the esophageal sphincter to relax and the esophageal muscles to propel food, making swallowing and the passage of food into the stomach difficult. The procedure is performed by a qualified healthcare provider and requires a thoracic approach.

5. When to use CPT code 43331

CPT code 43331 should be used when a provider performs esophagomyotomy through a thoracic approach. It is important to note that if the procedure is performed through an abdominal approach, a different CPT code should be used (43330). This code should only be used when the specific criteria for esophagomyotomy through a thoracic approach are met.

6. Documentation requirements

When reporting CPT code 43331, the provider must ensure that the following documentation is included:

• Patient’s diagnosis and the medical necessity for the procedure
• Details of the surgical procedure performed, including the thoracic approach
• Date of the procedure
• Any additional relevant information or complications encountered during the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT code 43331, it is important to follow the appropriate guidelines. Ensure that the procedure is performed through a thoracic approach and that the documentation supports the medical necessity of the procedure. It is also important to note that CPT code 43331 should not be reported with other codes unless specific circumstances warrant it. Additional tips for accurate billing can be obtained from the relevant coding resources.

8. Historical information

CPT code 43331 was added to the Current Procedural Terminology system on January 1, 1990. It has undergone no updates or changes since its addition. However, it is worth noting that Medicare added this procedure to the Inpatient Only (IPO) list in 2017, indicating that it is typically performed on an inpatient basis.

9. Examples

1. A patient with esophageal achalasia undergoes esophagomyotomy through a thoracic approach to improve the passage of food into the stomach.
2. A provider performs esophagomyotomy through a thoracic approach on a patient with difficulty swallowing due to esophageal dysfunction.
3. An individual with a history of esophageal achalasia undergoes esophagomyotomy through a thoracic approach to alleviate symptoms and improve their quality of life.
4. A provider performs esophagomyotomy through a thoracic approach on a patient with refractory gastroesophageal reflux disease (GERD) to improve the function of the esophageal sphincter.
5. A patient with esophageal motility disorders undergoes esophagomyotomy through a thoracic approach to enhance the movement of food through the esophagus.
6. An individual with dysphagia undergoes esophagomyotomy through a thoracic approach to alleviate their swallowing difficulties.
7. A provider performs esophagomyotomy through a thoracic approach on a patient with recurrent esophageal strictures to improve their ability to swallow.
8. An individual with a history of esophageal achalasia undergoes esophagomyotomy through a thoracic approach to prevent the regurgitation of food and reduce the risk of aspiration.
9. A patient with severe esophageal dysmotility undergoes esophagomyotomy through a thoracic approach to improve their ability to eat and drink.
10. A provider performs esophagomyotomy through a thoracic approach on a patient with a history of esophageal spasms to alleviate their symptoms and improve their quality of life.