Da Vinci Surgical System 2021 U.S. Coding & Reimbursement Guide
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Da Vinci Surgical System
2021 U.S. Coding &
Reimbursement Guide
Medicare National Average Rates
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2021 US Reimbursement and Coding Guide
.
Table of Contents
How to use this guide: intended use & audience ................................................................................................................................. 3
Disclaimers .......................................................................................................................................................................................... 4
Important safety information ................................................................................................................................................................ 5
Methodology & background ................................................................................................................................................................. 6
Reimbursement terminology & abbreviations ...................................................................................................................................... 7
2021 Medicare reimbursement ............................................................................................................................................................ 8
Appendectomy & other bowel procedures ....................................................................................................................................... 9
Bariatric procedures ....................................................................................................................................................................... 11
Colorectal procedures .................................................................................................................................................................... 12
Gastrectomy, Nissen fundoplication, & Heller myotomy procedures ............................................................................................. 15
Hepatobiliary & pancreatic procedures .......................................................................................................................................... 16
Hernia: inguinal, ventral, incisional, & other hernia repair .............................................................................................................. 18
Gynecology procedures ................................................................................................................................................................. 21
Otolaryngology procedures ............................................................................................................................................................ 25
Thoracic procedures ...................................................................................................................................................................... 26
Urology procedures ....................................................................................................................................................................... 29
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2021 US Reimbursement and Coding Guide
How to use this guide: intended use & audience
The intention of this guide is:
• To provide general coding and reimbursement information based on publicly available Medicare data for educational
purposes only.
• To provide US national average reimbursement rates based on Medicare publicly available fee schedules.
• To provide relevant supporting information about US coding and reimbursement.
The intended audience for this presentation is:
• Healthcare professionals involved in coding, documentation, claims processing, and/or reimbursement for relevant
procedures. This may include hospital and/or physician office billing professionals, coders, financial and/or revenue
integrity teams, and others who act in roles associated with the coding, coverage, and payment of relevant
procedures.
It is NOT intended for: healthcare providers and/or allied health professionals or other hospital and/or office staff who do not act in
above roles and capacities.
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2021 US Reimbursement and Coding Guide
Disclaimers
Intuitive is providing this information for educational purposes only, in support of accurate coding and reimbursement practices
based on Medicare coding, coverage, and payment. Intuitive cannot guarantee that this document is complete or without errors,
as coding, coverage, and payment are subject to change at any time. HCPCS codes listed in this guide represent no statement,
promise, or guarantee that these codes will be appropriate or that reimbursement will be made. This coding and
reimbursement guide cannot, under any circumstances, be interpreted as, or used in place of, clinical judgment. Any
coding and reimbursement decisions and practices are the sole responsibility of the provider and/or designated party
responsible for coding and reimbursement.
The Medicare Physician Fee schedule provides relative value units (RVU’s) broken into work, facility and non-facility practice
expense. To calculate facility and non-facility payments, RVU’s for facility and non-facility settings were multiplied against the
2021 conversion factor of $32.41.
Intuitive may not carry all products used in all procedures described. For more information, please also refer to
www.intuitive.com/safety
CPT is a registered trademark of the American Medical Association.
CPT© 2021 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or
related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA
does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or
not contained herein.
CPT© Assistant ©1990-2021 American Medical Association. All Rights Reserved.
CPT© Changes ©2006-2021 American Medical Association. All Rights Reserved.
The responsibility for the content of any "National Correct Coding Policy" included in this product is with the Centers for Medicare
and Medicaid Services and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for
any consequences or liability attributable to or related to any use, nonuse or interpretation of information contained in this product.
U.S. GOVERNMENT RIGHTS This product includes CPT© and/or CPT© Assistant and/or CPT© Changes which is commercial
technical data and/or computer data bases and/or commercial computer software and/or commercial computer software
documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515
North State Street, Chicago, Illinois, 60610. U.S. government rights to use, modify, reproduce, release, perform, display, or
disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are
subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of
DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable, for U.S. Department of Defense
procurements and the limited rights restrictions of FAR 52.227-14 (December 2007) and/or subject to the restricted rights
provisions of FAR 52.227-14 (December 2007) and FAR 52.227-19 (December 2007), as applicable, and any applicable agency
FAR Supplements, for non-Department of Defense Federal procurements.
Applicable FARS/DFARS Restrictions Apply to Government Use
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holders.
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2021 US Reimbursement and Coding Guide
Important safety information
Serious complications may occur in any surgery, including da Vinci ® surgery, up to and including death. Examples of serious or
life-threatening complications, which may require prolonged and/or unexpected hospitalization and/or reoperation, include but are
not limited to, one or more of the following: injury to tissues/organs, bleeding, infection and internal scarring that can cause long-
lasting dysfunction/pain.
Risks specific to minimally invasive surgery, including da Vinci surgery, include but are not limited to, one or more of the following:
temporary pain/nerve injury associated with positioning; a longer operative time, the need to convert to an open approach, or the
need for additional or larger incision sites. Converting the procedure could result in a longer operative time, a longer time under
anesthesia, and could lead to increased complications. Contraindications applicable to the use of conventional endoscopic
instruments also apply to the use of all da Vinci instruments.
For Important Safety Information, indications for use, risks, full cautions and warnings, please also refer to
www.intuitive.com/safety
Individuals' outcomes may depend on a number of factors, including but not limited to patient characteristics, disease
characteristics and/or surgeon experience.
© 2021 Intuitive Surgical, Inc. All rights reserved. Product names are trademarks or registered trademarks of their respective
holders.
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2021 US Reimbursement and Coding Guide
Methodology & background
This guide includes Healthcare Common Procedure Coding System (HCPCS) codes used by Medicare and other health insurers
to standardize coding in claims and other documentation. It is the responsibility of the provider and/or designated party
responsible for coding and reimbursement to determine the appropriate code(s) based on the situation.*
HCPCS codes are comprised of 2 levels, referred to as Level I and Level II of the HCPCS:
• Level I includes the Physicians’ Current Procedural Terminology Fourth Edition (CPT).** CPT is based on a numeric
coding system maintained by the American Medical Association (AMA) that describes medical services and
procedures provided by physicians and other health care professionals.
• In 2007, the AMA determined that no new CPT codes or unique identifiers were needed when describing laparoscopic
/ endoscopic procedures performed with robotic assistance.
• Level II codes are used to report durable medical equipment, supplies, non-physician services, and some drugs.
• S2900 (Surgical techniques requiring use of robotic surgical system) is a Level II code that was issued by a private
insurer in 2005. S2900 is not a code that is processed by Medicare. Note that other Level II codes are not shown in
this document.
*This guide is provided for educational purposes, and is not a comprehensive list of procedures. As the AMA publishes CPT codes on
an annual basis, and makes decisions regarding the addition, deletion, or revision of CPT codes throughout the year, this guide may
not reflect interim updates. Please refer to the most recent AMA publication of CPT® codes for additional information.
**CPT® 2021 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or
related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does
not directly or indirectly practice medicine or dispense medical services.
The AMA assumes no liability for data contained or not contained herein
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2021 US Reimbursement and Coding Guide
Reimbursement terminology & abbreviations
Reimbursement terminology used in this guide are briefly defined below in support of 2019 Medicare reimbursement
information. Unless otherwise noted, all definitions and sources available at the Centers of Medicare and Medicaid Services
(CMS) Glossary: www.cms.gov/apps/glossary/
1. American Medical Association (AMA): Professional organization for physicians that maintains the Physicians’ Current
Procedural Terminology (CPT) coding system.
2. Ambulatory Payment Classification (APC): Developed by CMS as the basis for hospital outpatient reimbursement rates;
relevant CPT codes are grouped into APCs based on resource utilization.
3. Ambulatory Surgery Center (ASC): Site of care for some services and procedures where patients are admitted, treated,
and discharged within 24 hours.
4. Centers for Medicare & Medicaid Services (CMS): Federal government agency within the Department of Health and
Human Services that administers public health programs. (See also "PPS")
5. Complications / Comorbidities (CC): Complications and diagnoses that determine appropriate diagnosis-related group
(DRG) for inpatient admission. (See also “MCC”.)
6. Conversion Factor (CF): Annual national multiplier used to convert geographically adjusted relative value units into
Medicare Physician Fee Schedule dollar amounts.
7. Current Procedural Terminology (CPT): See HCPCS Level I
8. Diagnosis-Related Group (DRG): Classification system that groups patients according to diagnosis, treatment type, and
other criteria. Under the US Inpatient Prospective Payment System (IPPS), hospitals are paid a set fee per patient based on
DRG category, regardless of actual cost of care. Only one DRG is assigned for each inpatient stay, regardless of the number
of procedures performed. DRGs shown in this guide are those typically assigned when a patient is admitted specifically for
the procedure described. All DRG reimbursement rates shown in this guide reflect estimated Medicare National Average
rates for 2021, inclusive of both operating and capital payments. (See also "PPS".)
9. Fee Schedule: List of codes and services with payment amounts (also referred to as reimbursement rates).
10. Healthcare Common Procedure Coding System (HCPCS) Level I: Numeric coding system used by physicians, other
health professionals, hospitals, and ambulatory surgical centers (ASC) to code procedures and services. HCPCS Level I is
comprised of the American Medical Association's Physicians' Current Procedural Terminology (CPT) codes. CPT codes have
been adopted by the Secretary of Health and Human Services as a standard to describe medical services and procedures
provided by physicians and other health care professionals.
11. Major Complications / Comorbidities (MCC): Complications and diagnoses indicating highest level of severity; also used to
determine diagnosis-related groups (DRG) for inpatient admissions. Complete Medicare MCC list published annually,
available at https://www.cms.gov/icd10m/version37-fullcode-cms/fullcode_cms/P0382.html
12. Medicare Physician Fee Schedule: Annual fee schedule published by CMS based on work, expense, and malpractice
designed to standardize physician payment.
13. Post-Acute Care Transfer (PACT) DRG: For some DRGs, Medicare may reduce payments when a patient’s length of stay
is 1 or more days less than the geometric mean LOS for that DRG, or if the patient is transferred to another Medicare-
covered acute care facility or post-acute setting. FY2021 Final DRG PACT designation available in Table 5,
https://edit.cms.gov/files/zip/fy-2021-ipps-fr-table-5.zip
14. Prospective Payment System (PPS): A method of reimbursement in which Medicare payment is made based on a
predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of
that service (for example, DRGs for inpatient hospital services)
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2021 US Reimbursement and Coding Guide
2021 Medicare reimbursement
All rates shown in the following section reflect 2021 Medicare national average rates, unadjusted by geography or other factors.
Medicare Hospital Inpatient data files available at https://www.cms.gov/medicare/acute-inpatient-pps/fy-2021-ipps-final-rule-home-
page
Medicare Hospital Outpatient data files, including Ambulatory Surgical Center (ASC) information, available at
https://edit.cms.gov/medicaremedicare-fee-service-paymentascpaymentasc-regulations-and-notices/cms-1736-fc
Medicare Physician Fee Schedule data files available at https://www.cms.gov/medicaremedicare-fee-service-
paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1734-f
National average Medicare Physician Fee Schedule rates based on 2021 conversion factor of $32.41 per “Final Policy, Payment,
and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021.” Available at
https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1734-f
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2021 US Reimbursement and Coding Guide
Appendectomy & other bowel procedures
2021 Medicare PACT DRG
DRG DRG description nat’l avg. rate applicable
Appendectomy procedures
338 Appendectomy w complicated principal diagnosis w MCC $17,989 No
339 Appendectomy w complicated principal diagnosis w CC $10,894 No
340 Appendectomy w complicated principal diagnosis w/o CC/MCC $7,895 No
341 Appendectomy w/o complicated principal diagnosis w MCC $14,887 No
342 Appendectomy w/o complicated principal diagnosis w CC $9,211 No
343 Appendectomy w/o complicated principal diagnosis w/o CC/MCC $7,131 No
Adrenalectomy procedures
614 Adrenal & pituitary procedures w CC/MCC $15,341 No
615 Adrenal & pituitary procedures w/o CC/MCC $10,117 No
Splenectomy procedures
799 Splenectomy w MCC $33,062 No
800 Splenectomy w CC $18,970 No
801 Splenectomy w/o CC/MCC $10,821 No
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2021 US Reimbursement and Coding Guide
(Appendectomy & other bowel procedures continued)
2021 Ambulatory
Medicare 2021 2021 ASC
Payment APC
® physician Medicare nat’l nat’l avg.
CPT Classification description
nat’l avg. rate avg. APC rate rate
Code Code description (APC)
(Facility)
Laparoscopy, surgical, with adrenalectomy,
60650 partial or complete, or exploration of adrenal $1,145
gland with or without biopsy, transabdominal,
lumbar or dorsal
Adrenalectomy, partial or complete, or exploration
of adrenal gland with or without biopsy, $1,040
60540 transabdominal, lumbar or dorsal (separate
procedure)
Adrenalectomy, partial or complete, or exploration
of adrenal gland with or without biopsy,
transabdominal, lumbar or dorsal (separate
60545 procedure); with excision of adjacent
retroperitoneal tumor $1,196
Appendectomy; for ruptured appendix with $845
44960
abscess or generalized peritonitis
Appendectomy; when done for indicated purpose
at time of other major procedure (not separate $80
44955 procedure) (List separately in addition to primary
procedure) Not applicable (Inpatient only)
Peritoneal &
abdominal
44950 Appendectomy $620 5341 procedures $3,183 $1413
Level 1
Laparoscopy
$580 $5,060 $2318
5361 and related
44970 Laparoscopy, surgical, appendectomy
services
Level 2
Laparoscopy
$1,017 and related $8,908 $3813
5362
38120 Laparoscopy, surgical, splenectomy services
38100 Splenectomy; total (separate procedure) $1,108
Splenectomy; total, en bloc for extensive disease,
38102 in conjunction with other procedure (List in addition
to code for primary procedure) $250 Not applicable (Inpatient only)
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2021 US Reimbursement and Coding Guide
Bariatric procedures
DRG DRG description 2021 Medicare nat’l PACT DRG
avg. rate applicable
619 O.R. procedures for obesity w MCC $19,675 No
620 O.R. procedures for obesity w CC $11,319
No
621 O.R. procedures for obesity w/o CC/MCC $10,261 No
Ambulatory
CPT® 2021 Medicare
Payment APC
Code Code description physician nat’l
Classification (APC) description
avg. rate (Facility)
Laparoscopy, surgical, gastric restrictive procedure;
43644 with gastric bypass and Roux-en-Y gastroenterostomy $1,671
(roux limb 150 cm or less)
Laparoscopy, surgical, gastric restrictive
43645 procedure; with gastric bypass and small intestine $1,768
reconstruction to limit absorption
43775 Laparoscopy, surgical, gastric restrictive $1,068
procedure; longitudinal gastrectomy (ie, sleeve
gastrectomy)
Not applicable (Inpatient only)
Gastric restrictive procedure with partial gastrectomy,
pylorus- preserving duodenoileostomy and
43845 $1,868
ileoileostomy (50 to 100 cm common channel) to limit
absorption (biliopancreatic diversion with duodenal
switch)
Gastric restrictive procedure, with gastric bypass for
43846 morbid obesity; with short limb (150 cm or less) $1,592
Roux-en-Y gastroenterostomy
43847 Gastric restrictive procedure, with gastric bypass for $1,743
morbid obesity; with small intestine reconstruction to
limit absorption
Revision, open, of gastric restrictive procedure for
43848 morbid obesity, other than adjustable gastric $1,860
restrictive device (separate procedure)
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2021 US Reimbursement and Coding Guide
Colorectal procedures
DRG DRG description 2021 Medicare PACT DRG
nat’l avg. rate applicable
329 Major small & large bowel procedures w MCC $31,175
Yes
330 Major small & large bowel procedures w CC $16,319 Yes
331 Major small & large bowel procedures w/o CC/MCC $10,992 Yes
332 Rectal resection w MCC $26,736
Yes
333 Rectal resection w CC $13,761
Yes
334 Rectal resection w/o CC/MCC $10,343 Yes
2021 Medicare Ambulatory
CPT® Code Code description physician nat’l avg. Payment
rate (Facility) Classification
(APC)
Colectomy
44204 Laparoscopy, surgical; colectomy, partial, with anastomosis $1,469
44205 Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum $1,275
with ileocolostomy
44206 Laparoscopy, surgical; colectomy, partial, with end colostomy and closure $1,671
of distal segment (Hartmann type procedure)
Not applicable
(Inpatient only)
44207 Laparoscopy, surgical; colectomy, partial, with anastomosis, $1,727
with coloproctostomy (low pelvic anastomosis)
44208 $1,883
Laparoscopy, surgical; colectomy, partial, with anastomosis,
with coloproctostomy (low pelvic anastomosis) with colostomy
44210 Laparoscopy, surgical; colectomy, total, abdominal, without proctectomy, $1,684
with ileostomy or ileoproctostomy
44212 Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, $1,935
with ileostomy
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2021 US Reimbursement and Coding Guide
(Colorectal procedures continued)
2021 Medicare physician Ambulatory
CPT® Code Code description nat’l avg. Payment
rate (Facility) Classification
(APC)
Colectomy
44140 Colectomy, partial; with anastomosis $1,288
44141 Colectomy, partial; with skin level cecostomy or colostomy $1,751
44143 Colectomy, partial; with end colostomy and closure of $1,596
distal segment (Hartmann type procedure)
Colectomy, partial; with resection, with colostomy or ileostomy and
44144 $1,694
creation of mucofistula
44147 Colectomy, partial; abdominal and transanal approach $1,852 Not applicable
(Inpatient only)
Colectomy, total, abdominal, without proctectomy; with ileostomy
44150 $1,785
or ileoproctostomy
44151 Colectomy, total, abdominal, without proctectomy; with continent $2,084
ileostomy
44155 Colectomy, total, abdominal, with proctectomy; with ileostomy $1,980
44156 Colectomy, total, abdominal, with proctectomy; with continent $2,231
ileostomy
Colectomy, total, abdominal, with proctectomy; with ileoanal
44157 anastomosis, includes loop ileostomy, and rectal $2,114
mucosectomy, when performed
44160 Colectomy, partial, with removal of terminal ileum with $1,191
ileocolostomy
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2021 US Reimbursement and Coding Guide
(Colorectal Procedures continued)
2021 Medicare physician Ambulatory
CPT® Code Code description nat’l avg. Payment
rate (Facility) Classification
(APC)
Proctectomy
45395 Laparoscopy, surgical; proctectomy, complete, combined $1,868
abdominoperineal, with colostomy
Laparoscopy, surgical; proctectomy, combined abdominoperineal pull-
through
45397 procedure (eg, colo-anal anastomosis), with creation of colonic reservoir $2,022
(eg, J-pouch), with diverting enterostomy, when performed
45110 Proctectomy; complete, combined abdominoperineal, with colostomy $1,746
45111 Proctectomy; partial resection of rectum, transabdominal approach $1,039
45112 Proctectomy, combined abdominoperineal, pullthrough $1,770
procedure (eg, colo-anal anastomosis)
45114 $1,750 Not applicable
Proctectomy, partial, with anastomosis; abdominal and transsacral
(Inpatient only)
approach
45116 Proctectomy, partial, with anastomosis; transsacral approach only (Kraske $1,458
type)
Proctectomy, combined abdominoperineal pull-through procedure (eg,
colo-anal
45119 anastomosis), with creation of colonic reservoir (eg, J-pouch), with $1,782
diverting
enterostomy when performed
Proctectomy, complete (for congenital megacolon), abdominal and
45120 perineal $1,541
approach; with pull-through procedure and anastomosis (eg,
Swenson, Duhamel, or Soave type operation)
45123 Proctectomy, partial, without anastomosis, perineal approach $1,061
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2021 US Reimbursement and Coding Guide
Gastrectomy, Nissen fundoplication, & Heller myotomy procedures
DRG DRG description 2021 Medicare PACT DRG
nat’l avg. rate applicable
326 Stomach, esophageal & duodenal proc w MCC $34,565 Yes
327 Stomach, esophageal & duodenal proc w CC $16,773 Yes
328 Stomach, esophageal & duodenal proc w/o CC/MCC $10,705 Yes
Ambulatory 2021
CPT® 2021 2021 ASC
Payment APC Medicare
Code Code description Medicare nat’l avg rate
Classification description nat’l avg.
physician rate
(APC) APC rate
(Facility)
43621 Gastrectomy, total; with Roux-en-Y $2,184
reconstruction
Gastrectomy, total; with formation of intestinal
43622 pouch, any type $2,226
Gastrectomy, partial, distal; with Roux-en-Y
43633 reconstruction $1,847
Gastrectomy, partial, distal; with formation of
43634 intestinal pouch $2,047
Esophagogastric fundoplasty; with fundic patch
43325 (Thal-Nissen procedure) $1,310
Esophagogastric fundoplasty partial or complete; Not applicable (Inpatient only)
43327 laparotomy $789
Esophagogastric fundoplasty partial or complete;
43328 thoracotomy $1,076
Esophagomyotomy (Heller type); abdominal
43330 approach $1,289
Esophagomyotomy (Heller type); thoracic
43331 approach $1,281
43279 Laparoscopy, surgical, esophagomyotomy $1,236
(Heller type), with fundoplasty, when performed
Esophagogastroduodenoscopy, flexible,
43210 transoral; with esophagogastric fundoplasty, $408
partial or complete, includes duodenoscopy when
performed
43280 Laparoscopy, surgical, $1,038 Level 2
esophagogastric fundoplasty (eg, Nissen, Laparoscopy
5362 $8,908 $3,813
Toupet procedures) and related
services
Laparoscopy, surgical, repair of
43281 paraesophageal hernia, includes fundoplasty, $1,482
when performed; without implantation of mesh
Laparoscopy, surgical, repair of
43282 paraesophageal hernia, includes fundoplasty, $1,666
when performed; with implantation of mesh
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2021 US Reimbursement and Coding Guide
Hepatobiliary & pancreatic procedures
2021 Medicare PACT DRG
DRG DRG description nat’l avg. rate applicable
Hepatobiliary procedures
411 Cholecystectomy w C.D.E. w MCC $24,118 No
412 Cholecystectomy w C.D.E. w CC $14,627 No
413 Cholecystectomy w C.D.E. w/o CC/MCC $11,128 No
414 Cholecystectomy except by laparoscope w/o C.D.E. w MCC $23,303 Yes
415 Cholecystectomy except by laparoscope w/o C.D.E. w CC $13,060 Yes
416 Cholecystectomy except by laparoscope w/o C.D.E. w/o CC/MCC $9,141 Yes
417 Laparoscope cholecystectomy w/o C.D.E. w MCC $15,577 No
418 Laparoscope cholecystectomy w/o C.D.E. w CC $10,850 No
419 Laparoscope cholecystectomy w/o C.D.E. w/o CC/MCC $8,453 No
Pancreatic procedures
405 Pancreas, liver & shunt procedures w MCC $36,832 Yes
406 Pancreas, liver & shunt procedures w CC $18,492 Yes
407 Pancreas, liver & shunt procedures w/o CC/MCC $13,600 Yes
628 Other endocrine, nutrit & metab O.R. procedures w MCC $23,769 Yes
629 Other endocrine, nutrit & metab O.R. procedures w CC $15,084 Yes
630 Other endocrine, nutrit & metab O.R. procedures w/o CC/MCC $9,043 Yes
CPT® Code description 2021 Medicare Ambulatory 2021 2021 ASC
physician nat’l Payment APC Medicare
Code nat’l avg rate
avg. rate Classification description nat’l avg.
(Facility) (APC) APC rate
Laparoscopy, surgical;
47562 cholecystectomy $637
Level 1
Laparoscopy, surgical; Laparoscopy and
47563 cholecystectomy with cholangiography $694 5361 $5,060 $2,318
related services
Laparoscopy, surgical;
47564 cholecystectomy with exploration $1,078
of common duct
47600 Cholecystectomy $1,031
47605 Cholecystectomy; with cholangiography $1,086 Not applicable (Inpatient only)
Cholecystectomy with exploration
47610 of common duct $1,209
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2021 US Reimbursement and Coding Guide
(Hepatobiliary & pancreatic procedures continued)
2021 Medicare Ambulatory
CPT® APC
physician nat’l Payment
Code Code description description
avg. rate Classification
(Facility) (APC)
48140 Pancreatectomy, distal subtotal, with or without splenectomy; $1,505
without pancreaticojejunostomy
48145 Pancreatectomy, distal subtotal, with or without splenectomy; $1,576
with pancreaticojejunostomy
48146 Pancreatectomy, distal, near-total with preservation of duodenum $1,824
(Child-type procedure)
Pancreatectomy, proximal subtotal with total duodenectomy,
48150 partial gastrectomy, choledochoenterostomy and $2,999 Not applicable
gastrojejunostomy (Whipple- type procedure); with (Inpatient only)
pancreatojejunostomy
Pancreatectomy, proximal subtotal with total duodenectomy,
48152 partial gastrectomy, choledochoenterostomy and $2,791
gastrojejunostomy (Whipple- type procedure); without
pancreatojejunostomy
Pancreatectomy, proximal subtotal with near-total duodenectomy,
48153 choledochoenterostomy and duodenojejunostomy (pylorus- $2,990
sparing, Whipple-type procedure); with pancreatojejunostomy
Pancreatectomy, proximal subtotal with near-total duodenectomy,
48154 choledochoenterostomy and duodenojejunostomy (pylorus- $2,803
sparing, Whipple-type procedure); without pancreatojejunostomy
48155 Pancreatectomy, total $1,758
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2021 US Reimbursement and Coding Guide
Hernia: inguinal, ventral, incisional, & other hernia repair
DRG DRG description 2021 Medicare PACT DRG
nat’l avg. rate Applicable?
350 Inguinal & femoral hernia procedures w MCC $15,763 No
351 Inguinal & femoral hernia procedures w CC $9,579 No
352 Inguinal & femoral hernia procedures w/o CC/MCC $7,089 No
353 Hernia procedures except inguinal & femoral w MCC $19,334 No
354 Hernia procedures except inguinal & femoral w CC $11,460 No
355 Hernia procedures except inguinal & femoral w/o CC/MCC $8,736 No
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2021 US Reimbursement and Coding Guide
(Hernia repair continued)
2021 Ambulatory 2021
CPT® Medicare 2021 ASC
Payment Medicare
Code Code description physician APC description nat’l avg rate
Classification nat’l avg.
nat’l avg. (APC) APC rate
rate
(Facility)
Inguinal hernia
49650 Laparoscopy, surgical; repair initial inguinal $418 Level 1
hernia Laparoscopy and
5361 related $5,060 $2,318
procedures
49651 Laparoscopy, surgical; repair recurrent $544
inguinal hernia
49505 Repair initial inguinal hernia, age 5 years $505
or older; reducible
Repair initial inguinal hernia, age 5 years
49507 or older; incarcerated or strangulated $567
Peritoneal & $3,183 $1,413
Repair recurrent inguinal hernia, any age; 5341 abdominal
49520 $611
reducible procedures
Repair recurrent inguinal hernia, any age;
49521 incarcerated or strangulated $692
49525 Repair inguinal hernia, sliding, any age $555
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2021 US Reimbursement and Coding Guide
(Hernia repair continued)
CPT® 2021 Medicare Ambulatory 2021 2021 ASC
Code Code description physician nat’l Payment APC Medicare nat’l avg
avg. Classification description nat’l avg. rate
rate (Facility) (APC) APC rate
Ventral, incisional, & other hernia
Laparoscopy, surgical, repair, ventral,
49652 $719
umbilical, spigelian or epigastric hernia
Level 1
(includes mesh insertion, when
5361 Laparoscopy
performed); reducible
and related $5,060 $2,318
Laparoscopy, surgical, repair, ventral, procedures
umbilical, spigelian or epigastric hernia
49653 $898
(includes mesh insertion, when
performed); incarcerated or
strangulated
Laparoscopy, surgical, repair, incisional
49654 hernia (includes mesh insertion, when $815
performed); reducible
49655 Laparoscopy, surgical, repair, incisional $998 Level 2
hernia (includes mesh insertion, when Laparoscopy
5362
performed); incarcerated or strangulated and related
$8,908 $3,813
procedures
Laparoscopy, surgical, repair, recurrent
49656 $883
incisional hernia (includes mesh
insertion, when performed); reducible
Laparoscopy, surgical, repair, recurrent
incisional hernia (includes mesh
49657 $1,271
insertion, when performed); incarcerated
or strangulated
49560 Repair initial incisional or ventral hernia; $711
reducible
49570 Repair epigastric hernia (eg, preperitoneal $406
fat); reducible (separate procedure)
49572 Repair epigastric hernia (eg, preperitoneal $501
fat); incarcerated or strangulated
5341 Peritoneal & $3,183 $1,413
abdominal
procedures
49550 Repair initial femoral hernia, any age; $557
reducible
49553 Repair initial femoral hernia, any age; $610
incarcerated or strangulated
49555 Repair recurrent femoral hernia; reducible $583
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2021 US Reimbursement and Coding Guide
Gynecology procedures
DRG DRG description 2021 Medicare PACT DRG
nat’l avg. rate applicable
739 Uterine, adnexa proc for non-ovarian/adnexal malignancy w MCC $24,564 No
740 Uterine, adnexa proc for non-ovarian/adnexal malignancy w CC $11,569 No
741 Uterine, adnexa proc for non-ovarian/adnexal malignancy w/o CC/MCC $8,224 No
742 Uterine & adnexa proc for non-malignancy w CC/MCC $11,036 No
743 Uterine & adnexa proc for non-malignancy w/o CC/MCC $7,278 No
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2021 US Reimbursement and Coding Guide
(Gynecology procedures continued)
2021 Medicare Ambulatory APC 2021
CPT® physician nat’l Payment description Medicare 2021 ASC
Code Code description avg. Classification nat’l avg. nat’l avg
rate (Facility) (APC) APC rate rate
$712 5361 Level 1
58541 Laparoscopy, surgical, supracervical Laparoscopy $5,060 $2,317
hysterectomy, for uterus 250 g or less; and related
procedures
Laparoscopy, surgical, supracervical
58542 hysterectomy, for uterus 250 g or less; with $810
removal of tube(s) and/or ovary(s)
Level 2
Laparoscopy, surgical, supracervical 5362 Laparoscopy $8,908 $3,813
58543 $823 and related
hysterectomy, for uterus greater than 250 g;
procedures
Laparoscopy, surgical, supracervical
58544 hysterectomy, for uterus greater than 250 g; $885
with removal of tube(s) and/or ovary(s)
Laparoscopy, surgical, with radical
hysterectomy, with bilateral total pelvic
58548 lymphadenectomy and para-aortic lymph $1,816 Not applicable (Inpatient only)
node sampling (biopsy), with removal of
tube(s) and ovary(s), if performed
Level 1
Laparoscopy surgical, with vaginal Laparoscopy
58550 hysterectomy, for uterus $860 5361 and related $5,060 $2,318
250 g or less; procedures
Laparoscopy surgical, with vaginal
58552 hysterectomy, for uterus 250 g or less; with $957
removal of tube(s) and/or ovary(s)
58553 Laparoscopy, surgical, with vaginal $1,094
hysterectomy, for uterus greater than 250 g;
Laparoscopy, surgical, with vaginal Level 2
58554 hysterectomy, for uterus greater than 250 g; $1,272 Laparoscopy
with removal of tube(s) and/or ovary(s) and related $8,908 $3,813
5362 procedures
58570 Laparoscopy, surgical, with total $781
hysterectomy, for uterus 250 g or
less;
Laparoscopy, surgical, with total
58571 hysterectomy, for uterus 250 g or less; with $878
removal of tube(s) and/or ovary(s)
58572 Laparoscopy, surgical, with total $1,008
hysterectomy, for uterus greater than 250 g;
Laparoscopy, surgical, with total
58573 hysterectomy, for uterus greater than 250 g; $1,179
with removal of tube(s) and/or ovary(s)
Laparoscopy, surgical, myomectomy, Level 1
excision; 1 to 4 intramural myomas with Laparoscopy
58545 $876 5361 $5,060 $2,318
total weight of 250 g or less and/or removal and Related
of surface myomas Procedures
Laparoscopy, surgical, myomectomy, Level 2
excision; 5 or more intramural myomas Laparoscopy
58546 $1,088 5362 $8,908 $3,813
and/or intramural myomas with total weight and Related
greater than 250 g Procedures
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2021 US Reimbursement and Coding Guide
(Gynecology procedures continued)
Ambulatory 2021
CPT® 2021 Medicare APC 2021 ASC
Code description Payment Medicare
Code physician nat’l description nat’l avg
Classification nat’l avg.
avg. rate rate
(APC) APC rate
(Facility)
58260 Vaginal hysterectomy, for uterus 250 g $818
or less
Vaginal hysterectomy, for uterus 250 g or
58262 less; with removal of tube(s), and/or $905
ovary(s) Level 5
5415 Gynecologic $1,873
Vaginal hysterectomy, for uterus 250 g or procedures $4,410
58263 less; with removal of tube(s), and/or $970
ovary(s), with repair of enterocele
Vaginal hysterectomy, for uterus 250 g or
58270 less; with repair of enterocele $872
Level 6
58290 Vaginal hysterectomy, for uterus greater $1,125 5416 Gynecologic $6,794 $2,801
than 250 g; procedures
Vaginal hysterectomy, for uterus greater Level 5
58291 than 250 g; with removal of tube(s) $1,216 5415 Gynecologic
and/or ovary(s) procedures $4,410 $1,873
Level 6
58292 Vaginal hysterectomy, for uterus greater $1,281 5416 Gynecologic $6,794 $2,801
than 250 g; with removal of tube(s) procedures
and/or ovary(s), with repair of enterocele
Level 5
58294 Vaginal hysterectomy, for uterus greater $1,189 5415 $4,410
Gynecologic $1,873
than 250 g; with repair of
procedures
enterocele
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2021 US Reimbursement and Coding Guide
(Gynecology procedures continued)
Ambulatory
CPT® 2021 Medicare Payment APC
Code description Classification
Code physician nat’l avg. description
rate (Facility) (APC)
Total abdominal hysterectomy (corpus and cervix), with or
58150 without removal of tube(s), with or without removal of $982
ovary(s);
Supracervical abdominal hysterectomy (subtotal
58180 hysterectomy), with or without removal of tube(s), with or $934
without removal of ovary(s)
Not applicable
(Inpatient only)
Total abdominal hysterectomy, including partial vaginectomy,
58200 with para-aortic and pelvic lymph node sampling, with or $1,307
without removal of tube(s), with or without removal of ovary(s)
Radical abdominal hysterectomy, with bilateral total pelvic
lymphadenectomy and para-aortic lymph node sampling
58210 $1,759
(biopsy), with or without removal of tube(s), with or without
removal of ovary(s)
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2021 US Reimbursement and Coding Guide
Otolaryngology procedures
PACT DRG
2021 Medicare
DRG DRG description Applicable?
nat’l avg. rate
140 Major head and neck procedures with MCC $25,585 No
141 Major head and neck procedures with CC $14,189
No
142 Major head and neck procedures without CC/MCC $10,340
No
143 Other ears, nose, mouth and throat O.R. procedures with MCC $19,050
No
144 Other ears, nose, mouth and throat O.R. procedures with CC $11,251
No
145 Other ears, nose, mouth and throat O.R. procedures without CC/MCC $7,800
No
2021 Ambulatory 2021
CPT® Medicare 2021
Payment APC Medicare nat’l
Code Code description physician description avg. ASC nat’l avg rate
Classification
nat’l avg. rate (APC) APC rate
(Facility)
Level 5 ENT
41120 Glossectomy; less than one-half $1,070 5165 $5,086 $2,399
procedures
tongue
Not applicable
41130 Glossectomy; hemiglossectomy $1,309 (Inpatient only procedures)
42842 Radical resection of tonsil, tonsillar $1,006
pillars, and/or retromolar trigone;
without closure 5165 Level 5 ENT $5,086 $2,399
procedures
Radical resection of tonsil, tonsillar
$1,368
pillars, and/or retromolar trigone;
42844
closure with local flap (eg, tongue,
buccal)
Radical resection of tonsil, tonsillar
42845 pillars, and/or retromolar trigone; $2,182 Not applicable
closure with other flap (Inpatient only procedures)
42870 Excision or destruction lingual tonsil, $596
any method (separate procedure) 5165 Level 5 ENT $5,086 $2,399
procedures
42890 Limited pharyngectomy $1,408
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2021 US Reimbursement and Coding Guide
Thoracic procedures
DRG DRG description 2021 Medicare PACT DRG
nat’l avg. rate applicable
Esophagectomy*
140 Major head and neck procedures with MCC $25,585 No
141 Major head and neck procedures with CC $14,189 No
142 Major head and neck procedures without CC/MCC $10,340 No
143 Other ears, nose, mouth and throat O.R. procedures with MCC $19,050 No
144 Other ears, nose, mouth and throat O.R. procedures with CC $11,251 No
145 Other ears, nose, mouth and throat O.R. procedures without CC/MCC $7,800 No
326 Stomach, esophageal & duodenal procedures w MCC $34,565 Yes
327 Stomach, esophageal & duodenal procedures w CC $16,773 Yes
328 Stomach, esophageal & duodenal procedures w/o CC/MCC $10,705 Yes
Thoracic procedures
163 Major chest procedures w MCC $31,877 Yes
164 Major chest procedures w CC $16,941 Yes
165 Major chest procedures w/o CC/MCC $12,267 Yes
*DRG assignment may vary based on principal diagnosis.
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2021 US Reimbursement and Coding Guide
(Thoracic procedures continued)
2021 Medicare Ambulatory
CPT® physician nat’l Payment APC
Code Code description avg. rate Classification description
(Facility) (APC)
Esophagectomy
Total or near total esophagectomy, without thoracotomy; with
43107 pharyngogastrostomy or cervical esophagogastrostomy, with or $2,845
without pyloroplasty (transhiatal)
Total or near total esophagectomy, without thoracotomy; with colon
43108 interposition or small intestine reconstruction, including intestine $4,242
mobilization, preparation and anastomosis(es)
Total or near total esophagectomy, with thoracotomy; with
43112 pharyngogastrostomy or cervical esophagogastrostomy, with or without $3,325
pyloroplasty
Total or near total esophagectomy, with thoracotomy; with colon
43113 interposition or small intestine reconstruction, including intestine $4,144
mobilization, preparation, and anastomosis(es)
43116 Partial esophagectomy, cervical, with free intestinal graft, including $4,742
microvascular anastomosis, obtaining the graft and intestinal reconstruction
Not applicable
(Inpatient only
procedures)
43117 Partial esophagectomy, distal two-thirds, with thoracotomy and separate $3,108
abdominal incision, with or without proximal gastrectomy; with thoracic
esophagogastrostomy, with or without pyloroplasty (Ivor Lewis)
Partial esophagectomy, distal two-thirds, with thoracotomy and separate
abdominal incision, with or without proximal gastrectomy; with colon
43118 $3,460
interposition or small intestine reconstruction, including intestine
mobilization, preparation, and anastomosis(es)
Partial esophagectomy, distal two-thirds, with thoracotomy only, with or
43121 without proximal gastrectomy, with thoracic esophagogastrostomy, with or $2,728
without pyloroplasty
Partial esophagectomy, thoracoabdominal or abdominal approach, with or
43122 without proximal gastrectomy; with esophagogastrostomy, with or without $2,438
pyloroplasty
Partial esophagectomy, thoracoabdominal or abdominal approach, with or
without proximal gastrectomy; with colon interposition or small intestine
43123 $4,296
reconstruction, including intestine mobilization, preparation, and
anastomosis(es)
Total or partial esophagectomy, without reconstruction (any approach),
43124 $3,632
with cervical esophagostomy
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2021 US Reimbursement and Coding Guide
(Thoracic procedures continued)
2021 Medicare Ambulatory
CPT® APC
Code Code description physician nat’l Payment
description
avg. Rate Classification
(Facility) (APC)
Thoracic procedures
Thoracotomy; with control of traumatic hemorrhage and/or repair of
32110 $1403
lung tear
32120 Thoracotomy; for postoperative complications $835
Thoracotomy; with cyst(s) removal, includes pleural procedure
32140 when performed $946
Thoracotomy; with resection-plication of bullae, includes any pleural
32141 procedure when performed $1,452
32160 Thoracotomy; with cardiac massage $760
32480 $1,411
Removal of lung, other than pneumonectomy; single lobe (lobectomy)
32482 $1,512
Removal of lung, other than pneumonectomy; 2 lobes (bilobectomy)
Removal of lung, other than pneumonectomy; single segment
32484 $1,367
(segmentectomy)
Thoracotomy; with therapeutic wedge resection (eg, mass, nodule),
32505 initial $889
Not applicable
Thoracotomy; with therapeutic wedge resection (eg, mass or nodule), (Inpatient only
32506 $148
each additional resection, ipsilateral (List separately in addition to procedures)
code for primary procedure)
32507 Thoracotomy; with diagnostic wedge resection followed by anatomic $148
lung resection (List separately in addition to code for primary
procedure)
32661 Thoracoscopy, surgical; with excision of pericardial cyst, tumor, or $763
mass
Thoracoscopy, surgical; with excision of mediastinal cyst, tumor, or
32662 mass $853
32663 Thoracoscopy, surgical; with lobectomy (single lobe) $1,334
Thoracoscopy, surgical; with therapeutic wedge resection (eg,
32666 mass, nodule), initial unilateral $831
Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass
32667 or nodule), each additional resection, ipsilateral (List separately in $149
addition to code for primary procedure)
Thoracoscopy, surgical; with diagnostic wedge resection followed by
32668 anatomic lung resection (List separately in addition to code for $149
primary procedure)
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2021 US Reimbursement and Coding Guide
Urology procedures
2021 Medicare PACT DRG
DRG DRG description
nat’l Avg. Rate applicable
656 Kidney & ureter procedures for neoplasm w MCC $21,093 No
657 Kidney & ureter procedures for neoplasm w CC $12,431 No
658 Kidney & ureter procedures for neoplasm w/o CC/MCC $10,150 No
659 Kidney & ureter procedures for non-neoplasm w MCC $17,128 Yes
660 Kidney & ureter procedures for non-neoplasm w CC $9,277 Yes
661 Kidney & ureter procedures for non-neoplasm w/o CC/MCC $6,841 Yes
665 Prostatectomy with MCC $19,518 No
666 Prostatectomy with CC $11,147 No
667 Prostatectomy without CC/MCC $6,395 No
707 Major male pelvic procedures w CC/MCC $12,344 No
708 Major male pelvic procedures w/o CC/MCC $9,586 No
2021
®
Medicare Ambulatory
CPT physician Payment APC
Code Code description
nat’l avg. Classification description
rate (APC)
(Facility)
Cystectomy
51550 Cystectomy, partial; simple $926
Cystectomy, partial; complicated (eg, postradiation, previous surgery,
51555 difficult location) $1,213
Cystectomy, partial, with reimplantation of ureter(s) into bladder
51565 (ureteroneocystostomy) $1,239
51570 Cystectomy, complete; (separate procedure) $1,411
Cystectomy, complete; with bilateral pelvic lymphadenectomy, including Not applicable
51575 external iliac, hypogastric, and obturator nodes $1,746 (Inpatient only)
Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous
51580 transplantations; $1,821
Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous
51585 transplantations; with bilateral pelvic lymphadenectomy, including external $2,026
iliac, hypogastric, and obturator nodes
Cystectomy, complete, with ureteroileal conduit or sigmoid bladder,
51590 including intestine anastomosis $1,853
Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including
51595 intestine anastomosis; with bilateral pelvic $2,097
lymphadenectomy, including external iliac, hypogastric, and obturator nodes
Cystectomy, complete, with continent diversion, any open technique, using
51596 any segment of small and/or large intestine to construct neobladder $2,260
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