Medicare CPT Code 47563 and 47564

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