How To Use CPT Code 43502

CPT 43502 describes the procedure of gastrotomy with suture repair of a pre-existing esophagogastric laceration, such as Mallory-Weiss tear. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 43502?

CPT 43502 is used to describe a surgical procedure that involves the repair of a pre-existing laceration in the lower esophagus as it enters the stomach. This procedure is performed to control bleeding, particularly in cases of Mallory-Weiss tears, which are often caused by excessive or continuous coughing or vomiting, commonly associated with alcohol abuse.

2. Official Description

The official description of CPT code 43502 is: ‘Gastrotomy; with suture repair of pre-existing esophagogastric laceration (eg, Mallory-Weiss).’ This procedure involves making an incision in the upper midline of the abdomen, followed by a high anterior lengthwise incision in the stomach to expose the gastroesophageal junction. The tear in the wall of the esophagus is then sutured, and additional steps are taken to ensure proper closure and inspection for any bleeding vessels.

3. Procedure

1. After appropriate patient preparation and anesthesia, the provider makes an incision in the upper midline of the abdomen.
2. A high anterior lengthwise incision is made in the stomach, extending it slightly into the esophagus to expose the gastroesophageal junction.
3. The tear in the wall of the esophagus is identified and sutured, and a biopsy specimen may be taken from one end of the laceration if necessary.
4. The area is irrigated to remove any clots or fluid, and the operative site is suctioned.
5. The provider inspects the area for any additional bleeding vessels and closes the anterior esophageal wall and stomach incisions in layers.
6. The suture lines are checked for bleeding, any instruments are removed, and the incision in the abdomen is closed.

4. Qualifying circumstances

CPT 43502 is performed in cases where there is a pre-existing esophagogastric laceration, such as a Mallory-Weiss tear. These tears are typically caused by severe continuous coughing or vomiting, often associated with alcohol abuse. The procedure is intended to control bleeding and repair the laceration. It is important to note that gastrotomy for Mallory-Weiss tear is rare today and would typically follow a failed attempt at endoscopic repair.

5. When to use CPT code 43502

CPT code 43502 should be used when performing a gastrotomy with suture repair of a pre-existing esophagogastric laceration, such as a Mallory-Weiss tear. It is important to ensure that the procedure is medically necessary and appropriate for the patient’s condition. This code should not be used for other types of gastrotomy procedures or repairs of different lacerations.

6. Documentation requirements

To support a claim for CPT 43502, the provider must document the following information:

• Patient’s diagnosis and the presence of a pre-existing esophagogastric laceration
• Details of the procedure, including the incisions made, repair of the tear, and any additional steps taken
• Biopsy specimen, if taken
• Irrigation and suctioning of the operative site
• Inspection for additional bleeding vessels
• Closure of the esophageal wall and stomach incisions
• Confirmation of absence of bleeding at the suture lines
• Removal of instruments
• Closure of the abdominal incision

7. Billing guidelines

When billing for CPT 43502, it is important to ensure that the procedure performed matches the description of the code. The provider should report this code only if the gastrotomy with suture repair of a pre-existing esophagogastric laceration is performed. It is also important to follow any specific billing guidelines provided by the payer or coding guidelines. It is recommended to review the documentation thoroughly and ensure accurate coding and billing practices.

8. Historical information

CPT 43502 was added to the Current Procedural Terminology system on January 1, 1995. The code has not undergone any updates since its addition. However, it is worth noting that in 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient with a Mallory-Weiss tear undergoes gastrotomy with suture repair to control bleeding.
2. Following a failed attempt at endoscopic repair, a patient with a pre-existing esophagogastric laceration undergoes gastrotomy with suture repair.
3. A provider performs gastrotomy with suture repair on a patient with a severe Mallory-Weiss tear caused by continuous coughing.
4. After a thorough evaluation, a patient with a pre-existing esophagogastric laceration undergoes gastrotomy with suture repair to address the bleeding.
5. A patient with a Mallory-Weiss tear caused by vomiting receives gastrotomy with suture repair to control the bleeding.
6. Following a diagnosis of a pre-existing esophagogastric laceration, a patient undergoes gastrotomy with suture repair to address the bleeding.
7. A provider performs gastrotomy with suture repair on a patient with a Mallory-Weiss tear resulting from alcohol abuse.
8. After failed attempts at endoscopic repair, a patient with a pre-existing esophagogastric laceration undergoes gastrotomy with suture repair to control the bleeding.