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The CPT® Code 43116 refers to a surgical procedure known as a partial esophagectomy, specifically performed in the cervical region. This complex operation involves the removal of a portion of the esophagus and the use of a free intestinal graft, which is typically a segment of the jejunum, to reconstruct the esophagus. The procedure is characterized by several key components: obtaining the intestinal graft, performing microvascular anastomosis, and reconstructing the intestines. The cervical esophagectomy is primarily indicated for patients with malignant neoplasms confined to the cervical area, although it may also be utilized in cases of benign strictures of the esophagus. During the procedure, an incision is made in the neck, usually on the left side, allowing access to the internal jugular vein and carotid artery, which are carefully retracted to expose the cervical esophagus. A second incision is made in the abdomen to harvest the intestinal graft, where a segment of the jejunum is identified and prepared for removal. The surgical team meticulously dissects the blood vessels supplying the jejunal segment, ensuring that the graft can be properly vascularized once placed in the neck. The procedure requires precise coordination among the surgical team, which may include a general surgeon, a head and neck surgeon, and a microvascular surgeon, to ensure successful graft placement and anastomosis. Overall, this procedure is a critical intervention for restoring esophageal continuity in patients with significant esophageal pathology.
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The procedure described by CPT® Code 43116 is indicated for specific medical conditions that necessitate surgical intervention on the esophagus. The primary indications include:
The surgical procedure for CPT® Code 43116 involves several detailed steps, each critical to the successful outcome of the operation. The steps are as follows:
After the completion of the procedure, patients typically require careful monitoring and post-operative care. This includes managing the surgical site for any signs of infection, ensuring proper healing of the anastomoses, and monitoring for any complications related to the graft. Patients may need nutritional support through the feeding tube placed in the jejunum until they can resume normal oral intake. Follow-up appointments are essential to assess the recovery process and the functionality of the graft, as well as to address any potential complications that may arise during the healing period.
| Short Descr | PARTIAL REMOVAL OF ESOPHAGUS | Medium Descr | PRTL ESOPHAGECTOMY CERVICAL W/FREE INTSTINAL GRF | Long Descr | Partial esophagectomy, cervical, with free intestinal graft, including microvascular anastomosis, obtaining the graft and intestinal reconstruction | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 94 - Other OR upper GI therapeutic procedures |
| 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) |
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| 1995-01-01 | Added | First appearance in code book in 1995. |
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