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2025 CPT code 43286

Laparoscopic-assisted near-total or total esophagectomy with open cervical esophagogastrostomy or pharyngogastrostomy; with or without pyloric drainage procedure.

Follow all applicable CPT coding guidelines for surgical procedures.Accurate documentation is essential for proper coding and reimbursement.

Modifiers may be applied depending on the circumstances (e.g., 58 for staged or related procedures).Consult the most current CPT guidelines for appropriate modifier usage.

Medical necessity for this procedure is established when a patient presents with esophageal cancer, severe esophageal injury requiring extensive resection, or spontaneous esophageal rupture requiring surgical repair. The decision to perform a laparoscopic-assisted versus a purely open approach should be based on clinical judgment, taking into account the patient’s overall condition and the extent of disease.

The surgeon is responsible for all aspects of the procedure, including pre-operative planning, intra-operative technique, and post-operative care.This may involve collaboration with other specialists such as anesthesiologists, gastroenterologists, and oncologists.

IMPORTANT:For a total or near-total esophagectomy with thoracoscopic mobilization, see code 43288; for resection/removal of the distal two-thirds of the esophagus with laparoscopic mobilization, see 43287.If only a diagnostic laparoscopy is performed, use code 49320.

In simple words: The surgeon removes most or all of the esophagus and the top part of the stomach using small incisions and a camera.The stomach is then reattached to the throat using an incision in the neck.In some cases, the surgeon also widens the opening between the stomach and small intestine.

This procedure involves the laparoscopic removal of all or most of the esophagus and the upper part of the stomach.The surgeon mobilizes the remaining portion of the esophagus behind the mediastinum (if any) using laparoscopic access. An open cervical approach is then used to connect the stomach to the pharynx (pharyngogastrostomy) or to the remaining esophagus (esophagogastrostomy). A pyloric drainage procedure may or may not be performed during the laparoscopic phase.

Example 1: A 60-year-old male patient presents with esophageal cancer.A laparoscopic-assisted near-total esophagectomy with open cervical esophagogastrostomy is performed to remove the cancerous tumor., A 55-year-old female patient has suffered a severe esophageal injury due to ingestion of caustic substances.A total esophagectomy with pharyngogastrostomy is performed using laparoscopic assistance., A 70-year-old male patient experiences a spontaneous esophageal rupture. A laparoscopic-assisted near-total esophagectomy with open cervical esophagogastrostomy and pyloroplasty is performed for repair.

Complete medical history, including details of the patient’s symptoms and any prior medical conditions.Preoperative imaging studies (e.g., endoscopy, CT scan, MRI) to confirm the diagnosis and extent of disease.Operative report detailing the procedure performed, including type of esophagectomy, method of anastomosis, and any complications.Pathology report confirming the diagnosis and staging of the disease.Postoperative progress notes documenting the patient’s recovery and any complications.Imaging studies (e.g., chest x-ray) post-operation to assess for any leaks or complications.

** This code encompasses a range of procedures, from near-total to total esophagectomy, with variation in the use of pyloric drainage.Precise documentation is essential to ensure appropriate reimbursement.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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