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The procedure described by CPT® Code 48540 involves the internal anastomosis of a pancreatic cyst to the gastrointestinal tract using a Roux-en-Y technique. This surgical intervention is typically indicated for patients with pancreatic cysts that require drainage to alleviate symptoms or prevent complications. The procedure begins with the surgeon making incisions, which can be bilateral subcostal or a midline abdominal incision, to access the cyst. Once the cyst is exposed, fluid is aspirated to confirm that it is indeed a fluid-filled cyst, and this step also allows for the assessment of the cyst wall's thickness. A biopsy may be performed on the cyst wall to exclude the possibility of malignancy. In this specific procedure, the cyst is anastomosed to the jejunum, which is part of the small intestine, through a Roux-en-Y limb. This technique involves mobilizing and dividing the jejunum, creating a Y-shaped configuration that facilitates drainage from the cyst into the gastrointestinal tract. The distal end of the divided jejunum is sutured to the cyst wall, while the proximal end is connected to the jejunum at a point approximately 40 cm away from the distal anastomosis. This method not only allows for effective drainage of the cyst but also minimizes the risk of complications associated with direct anastomosis to the stomach or duodenum. After the anastomosis is completed, drains are placed in the abdominal cavity, and the incision is closed, marking the completion of the procedure.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 48540 is indicated for the management of pancreatic cysts that require surgical intervention for drainage. The following conditions may warrant this procedure:
The procedure involves several critical steps to ensure successful anastomosis of the pancreatic cyst to the gastrointestinal tract. The following outlines the procedural steps:
Post-procedure care following the internal anastomosis of a pancreatic cyst to the gastrointestinal tract involves monitoring for complications and ensuring proper recovery. Patients may require observation for signs of infection, leakage from the anastomosis, or other postoperative complications. Pain management and nutritional support may be necessary as the patient recovers. The placement of drains will be monitored, and they may be removed based on the surgeon's assessment of the patient's condition. Follow-up appointments will be scheduled to evaluate the success of the procedure and to ensure that the cyst is adequately draining into the gastrointestinal tract.
| Short Descr | FUSE PANCREAS CYST AND BOWEL | Medium Descr | INT ANAST PANCREATIC CYST GI TRACT ROUX-EN-Y | Long Descr | Internal anastomosis of pancreatic cyst to gastrointestinal tract; Roux-en-Y | 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 | 99 - Other OR gastrointestinal therapeutic procedures |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) 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). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition |
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