How To Use CPT Code 43621

CPT 43621 describes the surgical procedure of total gastrectomy with Roux-en-Y reconstruction. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 43621?

CPT 43621 is used to describe the surgical removal of the entire stomach and the creation of an anastomosis between the distal divided small bowel and the stomach. This procedure is typically performed to treat certain conditions or diseases of the stomach, such as cancer or severe ulcers.

2. Official Description

The official description of CPT code 43621 is the surgical removal of the whole stomach and anastomosis of the distal divided small bowel to the stomach. This procedure is performed through an upper left paramedian incision, and the continuity of the alimentary canal is maintained with the anastomosis.

3. Procedure

1. The surgeon makes an upper left paramedian incision to access the abdominal cavity.
2. The spleen, including its hilar lymph nodes, splenic vessels, the tail, and the body of the pancreas, is mobilized from left to right.
3. The stomach, along with the lesser and greater omentum and lymph nodes around the celiac axis, is resected. The left gastric artery, right gastric artery, and epiploic arteries are ligated during this process.
4. The cut edge of the pancreas is closed with sutures.
5. An anastomosis is created between the distal divided small bowel and the stomach to maintain the continuity of the alimentary canal. The proximal end is anastomosed to the small bowel below the anastomosis.
6. Before closure, a drain is inserted up to the pancreas, and the other end is brought out through a separate stab incision at the subcostal region.

4. Qualifying circumstances

CPT 43621 is performed on patients who require the surgical removal of the entire stomach and the creation of an anastomosis with the small bowel. This procedure is typically indicated for conditions such as stomach cancer or severe ulcers that cannot be effectively treated with other interventions. The decision to perform this surgery is made by the physician based on the patient’s specific condition and medical history.

5. When to use CPT code 43621

CPT code 43621 should be used when a surgeon performs a total gastrectomy with Roux-en-Y reconstruction. This code is appropriate when the entire stomach is removed, and an anastomosis is created between the distal divided small bowel and the stomach. It is important to accurately document the details of the procedure to support the use of this code.

6. Documentation requirements

To support a claim for CPT 43621, the following documentation is required:

• Patient’s diagnosis necessitating the total gastrectomy
• Details of the surgical procedure, including the incision site and the steps performed
• Description of the anastomosis between the distal divided small bowel and the stomach
• Documentation of any additional procedures or interventions performed during the surgery
• Any complications or unexpected findings encountered during the procedure
• Signature of the performing surgeon

7. Billing guidelines

When billing for CPT 43621, ensure that the procedure performed matches the description of the code. It is important to accurately document the details of the surgery to support the use of this code. Additionally, be aware of any specific billing guidelines or requirements set forth by insurance providers or regulatory bodies.

8. Historical information

CPT 43621 was added to the Current Procedural Terminology system on January 1, 1994. The code has undergone no updates since its addition. However, it is important to stay updated with any changes or revisions to the code in future editions of the CPT manual.

9. Examples

1. A patient with stomach cancer undergoes a total gastrectomy with Roux-en-Y reconstruction to remove the entire stomach and create an anastomosis with the small bowel.
2. A patient with severe ulcers undergoes a total gastrectomy with Roux-en-Y reconstruction to alleviate symptoms and improve their quality of life.
3. A surgeon performs a total gastrectomy with Roux-en-Y reconstruction on a patient with a rare gastrointestinal disorder that necessitates the removal of the entire stomach.
4. A patient with a history of gastric bleeding undergoes a total gastrectomy with Roux-en-Y reconstruction to prevent further complications.
5. A patient with a large gastric tumor undergoes a total gastrectomy with Roux-en-Y reconstruction to remove the tumor and prevent its spread.
6. A surgeon performs a total gastrectomy with Roux-en-Y reconstruction on a patient with a genetic predisposition to stomach cancer.
7. A patient with a history of chronic gastritis undergoes a total gastrectomy with Roux-en-Y reconstruction to alleviate symptoms and improve their overall health.
8. A surgeon performs a total gastrectomy with Roux-en-Y reconstruction on a patient with a rare autoimmune disorder affecting the stomach.
9. A patient with a history of gastric ulcers undergoes a total gastrectomy with Roux-en-Y reconstruction to prevent further complications and improve their quality of life.
10. A surgeon performs a total gastrectomy with Roux-en-Y reconstruction on a patient with a large gastric polyp that cannot be effectively treated with other interventions.