Da Vinci Surgical System 2021 U.S. Coding & Reimbursement Guide

 
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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For additional assistance, please email us: reimbursementhelp@intusurg.com
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
 © 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

 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.

                                        ©2021 Intuitive Surgical, Inc. All rights reserved. Product and brand names/logos are trademarks or registered trademarks of Intuitive Surgical or their   5 of 32
PN1059294-US RevB 01/2021               respective owner. See www.intuitive.com/trademarks.
For additional assistance, please email us: reimbursementhelp@intusurg.com
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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For additional assistance, please email us: reimbursementhelp@intusurg.com
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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For additional assistance, please email us: reimbursementhelp@intusurg.com
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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 (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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 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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PN1059294-US RevB 01/2021               respective owner. See www.intuitive.com/trademarks.
For additional assistance, please email us: reimbursementhelp@intusurg.com
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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PN1059294-US RevB 01/2021                respective owner. See www.intuitive.com/trademarks.
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 (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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PN1059294-US RevB 01/2021               respective owner. See www.intuitive.com/trademarks.
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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

                                        ©2021 Intuitive Surgical, Inc. All rights reserved. Product and brand names/logos are trademarks or registered trademarks of Intuitive Surgical or their            18 of 32
PN1059294-US RevB 01/2021               respective owner. See www.intuitive.com/trademarks.
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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

                                         ©2021 Intuitive Surgical, Inc. All rights reserved. Product and brand names/logos are trademarks or registered trademarks of Intuitive Surgical or their         19 of 32
PN1059294-US RevB 01/2021                respective owner. See www.intuitive.com/trademarks.
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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

                                         ©2021 Intuitive Surgical, Inc. All rights reserved. Product and brand names/logos are trademarks or registered trademarks of Intuitive Surgical or their          20 of 32
PN1059294-US RevB 01/2021                respective owner. See www.intuitive.com/trademarks.
For additional assistance, please email us: reimbursementhelp@intusurg.com
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

                                        ©2021 Intuitive Surgical, Inc. All rights reserved. Product and brand names/logos are trademarks or registered trademarks of Intuitive Surgical or their           21 of 32
PN1059294-US RevB 01/2021               respective owner. See www.intuitive.com/trademarks.
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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

                                        ©2021 Intuitive Surgical, Inc. All rights reserved. Product and brand names/logos are trademarks or registered trademarks of Intuitive Surgical or their               22 of 32
PN1059294-US RevB 01/2021               respective owner. See www.intuitive.com/trademarks.
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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

                                        ©2021 Intuitive Surgical, Inc. All rights reserved. Product and brand names/logos are trademarks or registered trademarks of Intuitive Surgical or their           23 of 32
PN1059294-US RevB 01/2021               respective owner. See www.intuitive.com/trademarks.
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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)

                                        ©2021 Intuitive Surgical, Inc. All rights reserved. Product and brand names/logos are trademarks or registered trademarks of Intuitive Surgical or their             24 of 32
PN1059294-US RevB 01/2021               respective owner. See www.intuitive.com/trademarks.
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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

                                         ©2021 Intuitive Surgical, Inc. All rights reserved. Product and brand names/logos are trademarks or registered trademarks of Intuitive Surgical or their           25 of 32
PN1059294-US RevB 01/2021                respective owner. See www.intuitive.com/trademarks.
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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.

                                        ©2021 Intuitive Surgical, Inc. All rights reserved. Product and brand names/logos are trademarks or registered trademarks of Intuitive Surgical or their   26 of 32
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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

                                        ©2021 Intuitive Surgical, Inc. All rights reserved. Product and brand names/logos are trademarks or registered trademarks of Intuitive Surgical or their             27 of 32
PN1059294-US RevB 01/2021               respective owner. See www.intuitive.com/trademarks.
For additional assistance, please email us: reimbursementhelp@intusurg.com
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)

                                        ©2021 Intuitive Surgical, Inc. All rights reserved. Product and brand names/logos are trademarks or registered trademarks of Intuitive Surgical or their      28 of 32
PN1059294-US RevB 01/2021               respective owner. See www.intuitive.com/trademarks.
For additional assistance, please email us: reimbursementhelp@intusurg.com
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

                                        ©2021 Intuitive Surgical, Inc. All rights reserved. Product and brand names/logos are trademarks or registered trademarks of Intuitive Surgical or their             29 of 32
PN1059294-US RevB 01/2021               respective owner. See www.intuitive.com/trademarks.
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