How To Use CPT Code 48540

CPT 48540 describes the internal anastomosis of a pancreatic cyst to the gastrointestinal tract, specifically using a Roux-en-Y configuration. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 48540?

CPT 48540 can be used to describe the surgical procedure in which a connection is created between a cyst in the pancreas and the gastrointestinal tract, typically the small intestine, using a Roux-en-Y configuration. This allows for internal drainage of the cyst’s contents, reducing pain and preventing complications such as internal bleeding.

2. Official Description

The official description of CPT code 48540 is: ‘Internal anastomosis of pancreatic cyst to gastrointestinal tract; Roux-en-Y.’

3. Procedure

1. The provider begins by making an upper midline incision in the abdomen and dissecting down to the pancreas.
2. After inspecting the upper abdomen, the provider divides the small intestine.
3. Next, the provider connects the distal portion of the small intestine to the cyst in the pancreas through an incision in the cyst wall.
4. The proximal portion of the small intestine is then reconnected to the distal portion in an end-to-side fashion, creating the Roux-en-Y formation.
5. The area is irrigated, checked for bleeding, and any instruments are removed before closing the incision.

4. Qualifying circumstances

CPT 48540 is performed on patients with a pancreatic cyst that requires internal drainage. The procedure is typically indicated when the cyst is causing pain or there is a risk of complications such as internal bleeding. The provider must create an anastomosis between the cyst and the gastrointestinal tract using a Roux-en-Y configuration.

5. When to use CPT code 48540

CPT code 48540 should be used when the provider performs an internal anastomosis of a pancreatic cyst to the gastrointestinal tract using a Roux-en-Y configuration. This code is specific to this procedure and should not be used for other types of anastomosis or cyst drainage techniques.

6. Documentation requirements

To support a claim for CPT 48540, the provider must document the following information:

• Patient’s diagnosis and the need for internal drainage of the pancreatic cyst
• Details of the procedure, including the use of a Roux-en-Y configuration
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 48540, ensure that the procedure performed matches the description of the code. It is important to use the correct code for the specific anastomosis procedure performed. There are no specific guidelines regarding reporting CPT 48540 with other codes.

8. Historical information

CPT 48540 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. In 2017, it was added to the Inpatient Only (IPO) list for Medicare reimbursement purposes.

9. Examples

1. A patient with a large pancreatic cyst undergoes CPT 48540 to create an internal connection to the gastrointestinal tract using a Roux-en-Y configuration.
2. A provider performs CPT 48540 on a patient with a symptomatic pancreatic cyst to alleviate pain and prevent complications.
3. During surgery, the provider performs CPT 48540 to internally drain a pancreatic cyst and improve the patient’s quality of life.
4. A patient with a pancreatic cyst that is causing internal bleeding undergoes CPT 48540 to establish internal drainage and prevent further complications.
5. A provider performs CPT 48540 on a patient with a large pancreatic cyst to reduce pain and improve overall pancreatic function.
6. During the procedure, the provider creates an internal connection between a pancreatic cyst and the gastrointestinal tract using a Roux-en-Y configuration, coded as CPT 48540.
7. A patient with a pancreatic cyst undergoes CPT 48540 to alleviate symptoms and improve their overall health.
8. During surgery, the provider performs CPT 48540 to internally drain a pancreatic cyst and prevent future complications.
9. A provider performs CPT 48540 on a patient with a large pancreatic cyst to improve their quality of life and reduce the risk of complications.
10. A patient with a symptomatic pancreatic cyst undergoes CPT 48540 to alleviate pain and improve their overall well-being.