CPT 47563 , 47564 CHOLECYSTECTOMY
47563 Laparoscopy, surgical; cholecystectomy with cholangiography
Medical Necessity Guidelines: Cholecystectomy-Open and Laparoscopic
Note: While you may not be the provider responsible for obtaining prior authorization, as a condition of payment you will need to make sure that prior authorization has been obtained. Tufts Health Plan requires the use of an InterQual SmartSheet to obtain prior authorization for Cholecystectomies.
In order to obtain prior authorization for procedure(s), choose appropriate InterQual SmartSheet(s) listed below. The completed SmartSheet(s) must be sent to the applicable fax number listed above, according to Plan.
Cholecystectomy, Laparoscopic
Cholecystectomy, Laparoscopic, Cholangiogram Intraoperative with Laparoscopic Cholecystectomy
Cholecystectomy, Open
Cholecystectomy, Open, Cholangiogram Intraoperative with Open Cholecystectomy
CHOLECYSTECOMY,LAPAROSCOPIC,CHOLANGIOGRAM INTRAOPERATIVE WITH LAP CHOLECYSTECOMY
The following CPT code(s) require prior authorization:
Code & Description
47563 Laparoscopy, surgical; cholecystectomy with cholangiography
Denominator & Definition
Any member who underwent an appendectomy or cholecystectomy
(laparoscopic or other) during the 365 day period ending 30 days prior to the end of the measurement year.
Denominator & Codes
Appendectomy or laparoscopic appendectomy
CPT code(s): 44950, 44955, 44960, 44970
Cholecystectomy or laparoscopic cholecystectomy
CPT code(s): 47562, 47563, 47564, 47600, 47605, 47610, 47612, 47620
Covariates descriptions:
Procedure type: This variable allows the model to adjust for type of surgery (open vs. laparoscopic) performed.
Type 1: Laparoscopic appendectomy = CPT code: 44970
Type 2: Appendectomy = CPT code(s): 44950, 44955, 44960,
Type 3: Laparoscopic cholecystectomy = CPT procedure code(s): 47562, 47563, 47564
Type 4: Cholecystectomy = CPT code(s): 47600, 47605, 47610, 47612, 47620
APPLICABLE CODES
The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service.
Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.
CPT Code Description
47562 Laparoscopy, surgical; cholecystectomy
47563 Laparoscopy, surgical; cholecystectomy with cholangiography
CPT Code Description
47564 Laparoscopy, surgical; cholecystectomy with exploration of common duct
PROCEDURES REQUIRING PRE–CERTIFICATION FOR ALASKA DEPARTMENT OF HEALTH & SOCIAL SERVICES MEDICAL ASSISTANCE RECIPIENTS
Procedure : Cholecystectomy
ICD–9 CM Procedure Code : 51.21 through 51.24
CPT® Code : 47562, 47563, 47564, 47600, 47605, 47610, 47612, 47620
We are finalizing our proposal to review these codes as potentially misvalued codes.
CPT codes 47560 (Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy), 47562 (Laparoscopy, surgical; cholecystectomy) and 47563 (Laparoscopy, surgical; cholecystectomy with cholangiography) were proposed as potentially misvalued because the more extensive code (CPT 47560) has lower work RVUs than the less extensive codes (CPT 47562 and CPT 47563).
Comment: We received a comment suggesting that these codes were not potentially misvalued and urging us not to finalize our proposal, stating that 47562 and 47563 describe more complex surgical procedures and both have a 090-day global period while 47560 has a 000-day global period.
Patient sample criteria for the General Surgery Measures Group are: patients aged 18 years and older with specific surgical procedures performed:
The general surgery measures group is relevant to the following surgical procedures: Ventral Hernia, Appendectomy, AV Fistula, Cholecystectomy, Thyroidectomy, Mastectomy +/- Lymphadenectomy or Sentinel Lymph Node Biopsy (SLNB), Partial Mastectomy or Breast Biopsy/Lumpectomy +/- Lymphadenectomy or SLNB, Bariatric Laparoscopic or Open Roux en Y Gastric Bypass, Bariatric Sleeve Gastrectomy, Colectomy
• One of the following procedure codes indicating general surgery: 19101, 19301, 19302, 19303, 19304, 19305, 19306, 19307, 36818, 36819, 36820, 36821, 36825, 36830, 43644, 43645, 43775, 43846, 43847, 44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44160, 44204, 44205, 44206, 44207, 44208, 44210, 44950, 44960, 44970, 47562, 47563, 47564, 47600, 47605, 47610, 49560, 49561, 49565, 49566, 49572, 49585, 49587, 49590, 49652, 49653, 49654, 49655, 49656, 49657, 60200, 60210, 60212, 60220, 60225, 60240, 60252, 60254, 60260, 60270, 60271
Measure : Perioperative Care: Timing of Prophylactic Parenteral Antibiotic – Ordering Physician
Added to Denominator Coding (Biliary section), CPT Codes 47400, 47562, 47563, 47564, 47630, and 47801
Meaure : Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin
Added to Denominator Coding (Biliary section), CPT Codes 47400, 47562, 47563, 47564, 47630, and 47801
Measure : Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures)
Added to Denominator Coding (Biliary section), CPT Codes 47400, 47562, 47563, 47564, 47630, and 47801
DENOMINATOR:
All patients evaluated by an eligible professional as part of a trauma activation or trauma consultation who were taken to the operating room for an abdominal operation.
Denominator Instructions: CPT Category I procedure codes billed by surgeons performing surgery on the same patient, submitted with modifier 62 (indicating two surgeons, ie, dual procedures) will be included in the denominator population. Both surgeons participating in PQRS will be fully accountable for the clinical action described in the measure.
Denominator Criteria (Eligible Cases):
Patients evaluated as part of a trauma activation or trauma consultation
AND
Patients taken to the operating room for abdominal operation
AND
One of the following CPT codes for the patient encounter during the reporting period: Listed below are surgical procedures that may occur during abdominal surgery following trauma.
SURGICAL PROCEDURE : Biliary
CPT Code : 47400, 47420, 47425, 47460, 47480, 47560, 47561, 47562, 47563, 47564, 47570, 47579, 47600, 47605, 47610, 47612, 47620, 47701, 47715, 47720, 47721, 47740, 47741, 47760, 47765, 47780, 47785, 47800, 47801, 47802, 47900, 47999
Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedures:
The following procedures do NOT require PA if performed in a participating ASC or Outpatient Hospital setting:
Lap Cholecystectomy 47562, 47563, 47564
47563 Laparoscopy, surgical; cholecystectomy with cholangiography
47564 Laparoscopy, surgical; cholecystectomy with exploration of common duct
Wound Classification Field
The WOUND CLASSIFICATION field (#1.09) prevents the selection of “CLEAN” if the principal procedure code (CPT) matches one of the CPT’s that cannot be classified as clean. However, if data has already been populated for this field and the user tries to update it again, then the “CLEAN’ option will be displayed.
The CPT codes are:
43108,43113,43118,43123,43361,43645,43845,43847,44020,44021,44110,44111,44120,44121,44125,44126,44127, 44128,44139,44140,44141,44143,44144,44145,44146,44147,44150,44151,44155,44156,44157,44157,44158,44158, 44160,44202,44203,44204,44205,44206,44207,44208,44210,44211,44212,44213,44227,44322,44602,44603,44620, 44625,44625,44626,44626,44701,44900,44950,44955,44960,44970,45000,45005,45020,45108,45111,45113,45119, 45120,45121,45126,45130,45135,45160,45171,45172,45190,45355,45390,45397,45562,45563,45910,46040,46060, 46288,46707,47010,47120,47122,47125,47130,47133,47140,47141,47142,47143,47144,47145,47361,47400,47420, 47425,47480,47490,47510,47511,47525,47530,47550,47552,47560,47561,47562,47563,47564,47570,47600,47605, 47610,47612,47620,47700,47700,47711,47712,47720,47721,47740,47741,47760,47765,47780,47785,47800,47802, 47900,48001,48001,48020,48105,48140,48145,48146,48150,48152,48153,48154,48155,48160,48500,48510,48520, 48540,48545,48547,48548,48550,48551,48551,48552,48554,48556,49020,49407,49442,49450,50815,50825,50845, 51596,51597,51597,58200,58240,58260,58262,58263,58267,58270,58275,58280,58285,58290,58291,58292,58293, 58294,58550,58552,58553,58554,59857,0184T
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