2025 CPT code 43130
(Active) Effective Date: N/A Revision Date: N/A Surgery - Excision Procedures on the Esophagus Surgery Feed
Surgical removal of a diverticulum from the hypopharynx or esophagus through a cervical incision, with or without myotomy.
Modifiers may apply depending on the circumstances of the procedure.For example, modifier 22 (increased procedural services) might be appropriate if the procedure was significantly more complex than usual, while modifier 51 (multiple procedures) would be used if multiple procedures were performed on the same day.Always consult current modifier guidelines.
Medical necessity is established by the presence of symptoms directly attributable to the diverticulum (e.g., significant dysphagia, aspiration pneumonia, significant weight loss, recurrent infections). Conservative management options such as dietary modifications must be documented as unsuccessful.
The otolaryngologist or surgeon is responsible for pre-operative assessment, including imaging and evaluation of swallowing function. They perform the surgical procedure under general anesthesia, including incision, diverticulectomy, repair, and wound closure. Post-operative care and follow-up are also the responsibility of the surgeon.
In simple words: The doctor removes a pouch from the throat or food pipe through a cut in the neck. This pouch is an abnormal bulge that can make it hard to swallow. The doctor might also make a small cut in a muscle to prevent the pouch from coming back.
This CPT code encompasses the surgical excision of a diverticulum (an abnormal pouch or sac) located in the hypopharynx or esophagus.The procedure is performed via a cervical (neck) approach.The surgeon will incise the neck skin, expose the diverticulum, and remove it using techniques such as excision or oversewing.Repair of the hypopharynx or esophagus in layers follows, along with irrigation and layered wound closure. A myotomy (incision of muscle) may be included to prevent recurrence, specifically to the cricopharyngeus muscle.This procedure addresses conditions causing swallowing difficulties, regurgitation, and potential weight loss.
Example 1: A 65-year-old male presents with dysphagia, regurgitation, and weight loss.Endoscopy reveals a large Zenker's diverticulum in the hypopharynx.An open surgical excision (43130) is performed., A 72-year-old female with a history of chronic dysphagia undergoes a cervical approach diverticulectomy (43130) for a hypopharyngeal diverticulum. A myotomy is performed to reduce recurrent risk., A 58-year-old male presents with a small esophageal diverticulum causing intermittent dysphagia.A cervical approach diverticulectomy (43130) is selected to resolve his symptoms.
* Detailed history and physical examination documenting symptoms (dysphagia, regurgitation, weight loss).* Pre-operative imaging studies (barium swallow, endoscopy) confirming the diagnosis and location of the diverticulum.* Operative report detailing the surgical approach, techniques used for diverticulectomy, and any additional procedures (e.g., myotomy).* Pathology report if tissue is sent for analysis.* Post-operative progress notes documenting recovery and any complications.
** Accurate coding depends on thorough documentation of the surgical approach, the extent of the procedure, and any additional procedures performed.Always review payer-specific guidelines for any local coverage determinations or specific billing instructions.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- RVU: Refer to the most current Medicare Physician Fee Schedule for RVU values and reimbursement rates.These values vary based on geographic location and other factors.
- Global Days: The global period for this procedure will vary depending on payer and local practice norms.Check payer guidelines for specific details.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier is not applicable to this code as it represents the entire procedure.
- Fee Schedule: Refer to historical Medicare Physician Fee Schedules for past reimbursement rates.These are readily available online through the CMS website.
- Specialties:Otolaryngology, General Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgery Center