Cytoreductive Surgery and HIPEC

CPT 49200

CPT49200

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Add-on / Variant CPTs

49201 — Excision of abdominal tumor, extensive (>2 organs or retroperitoneal)
38100 wRVU: 19.06 — Splenectomy (if performed as part of cytoreduction)
44120 wRVU: 20.3 — Small bowel resection (if required)
96549 wRVU: 0.0 — Unlisted chemotherapy injection (HIPEC; confirm payer)

Preoperative Diagnosis:

[Appendiceal mucinous neoplasm / colorectal peritoneal metastasis / ovarian cancer / mesothelioma] with peritoneal carcinomatosis

Postoperative Diagnosis:

Same

Procedure Performed:

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), [completeness of cytoreduction CC-0 / CC-1]

Attending Surgeon:

[Attending name], MD

First Assistant:

[Fellow/Resident name]

Anesthesia:

General endotracheal. Arterial line, central venous access. Cell saver. Epidural [if placed].

Indications:

Patient presents with [appendiceal mucinous neoplasm / colorectal peritoneal metastasis / primary peritoneal mesothelioma] and peritoneal carcinomatosis (PCI [X]) deemed resectable after multidisciplinary tumor board review. [Prior systemic chemotherapy: X cycles.] No distant metastatic disease on staging imaging. Risks including prolonged operative time, anastomotic leak, bowel obstruction, hematologic toxicity from HIPEC, and mortality discussed. Consent obtained.

Findings:

Peritoneal Carcinomatosis Index (PCI): [X] (scored 0-39). Regions involved: [list regions]. [Liver surface involved ([stripped / not stripped])]. [Spleen involved; splenectomy performed.] Completeness of cytoreduction: [CC-0: no visible residual disease / CC-1: residual <2 .5 mm]< span>.

Description of Procedure:

The patient was positioned supine. A midline laparotomy was performed from xiphoid to pubis. Systematic exploration was performed with PCI scoring of all 13 abdominal regions.
CYTOREDUCTION: the following procedures were performed (see individual procedure notes or detailed below): - [Pelvic peritonectomy and resection of pelvic tumor deposits] - [Right and/or left diaphragm peritoneal stripping] - [Greater omentectomy] - [Splenectomy / left upper quadrant peritonectomy] - [Right upper quadrant peritonectomy, cholecystectomy] - [Small bowel resection with primary anastomosis, [X] cm resected] - [Colorectal resection with [primary anastomosis / diverting ileostomy]] Completeness of cytoreduction: CC-[0/1]: [no visible residual / residual nodules <2 .5 mm]< span>.
HIPEC: Following cytoreduction and prior to bowel anastomosis, the abdomen was irrigated with [warmed / hyperthermic] chemotherapy solution. [Mitomycin C [X] mg/m2 / Oxaliplatin [X] mg/m2 / Cisplatin and doxorubicin] was administered intraperitoneally at [42 degrees C] for [60 / 90] minutes using a [closed / open Coliseum] technique. Outflow temperature maintained at [41-43 degrees C]. Chemotherapy was then drained and the abdomen irrigated with normal saline.
Bowel anastomoses were then performed [end-to-end / side-to-side with GIA stapler]. Hemostasis confirmed throughout. Closed-suction drains placed. Fascia closed with running [0-PDS]. Skin closed. Patient tolerated the procedure well.

Complications:

None

Specimens:

All resected specimens to pathology with individual labeling

Estimated Blood Loss:

[X] mL

Drains:

[Jackson-Pratt drains x2-3 in pelvis and right upper quadrant / None]

Disposition:

Patient taken to surgical ICU intubated in stable condition.

Epic SmartPhrase Version

PREOPERATIVE DIAGNOSIS: [Appendiceal mucinous neoplasm / colorectal peritoneal metastasis / mesothelioma] with peritoneal carcinomatosis
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Cytoreductive surgery + HIPEC, CC-[0/1]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; arterial line; CVP; cell saver

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [appendiceal / colorectal peritoneal / mesothelioma] peritoneal carcinomatosis (PCI ***) deemed resectable by multidisciplinary tumor board. No distant metastasis. Risks including prolonged OR time, anastomotic complications, HIPEC toxicity, and mortality discussed. Informed consent obtained.

FINDINGS: PCI *** (0-39). Regions: ***. Completeness of cytoreduction: CC-[0 / 1]. [Splenectomy / diaphragm stripping / bowel resection] required.

DESCRIPTION OF PROCEDURE:
Patient supine. Midline laparotomy; systematic exploration; PCI scored. Cytoreduction: [pelvic peritonectomy / diaphragm stripping / greater omentectomy / splenectomy / cholecystectomy / small bowel resection *** cm / colorectal resection with [anastomosis / diverting ileostomy]]. CC-[0/1] achieved. HIPEC: [Mitomycin C *** mg/m2 / Oxaliplatin *** mg/m2] at 42 degrees C for [60/90] min, [closed / Coliseum] technique; abdomen irrigated with saline post-HIPEC. Bowel anastomoses performed. Hemostasis confirmed. Drains placed. Fascia with 0-PDS; skin closed. Patient tolerated procedure well.

ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: All resected specimens to pathology individually labeled
COMPLICATIONS: None
DRAINS: JP drains x*** in [pelvis / RUQ]
DISPOSITION: Patient to SICU intubated, stable.

Signed: .ME, .MYDEGREE
.TODAY

Variants

Appendiceal mucinous neoplasm (LAMN/HAMN/PMP)

Low-grade appendiceal mucinous neoplasm with pseudomyxoma peritonei (PMP). Mucinous deposits often easily stripped. Document viscosity of mucin (watery vs. gelatinous) and all regions stripped. CC-0 is achievable and prognostically important.

Ovarian cancer cytoreduction (interval or primary)

Gynecologic oncology often performs pelvic components; general surgery performs bowel resection and upper abdominal cytoreduction. Document team roles and each resection performed.

Charting Tips

Document PCI score systematically (score all 13 regions from 0-3 each, total 0-39)
State completeness of cytoreduction (CC score), as this is the most important prognostic factor
Document HIPEC agent, dose, temperature, duration, and technique (open vs. closed)
List every resection performed, as each is separately billable
Note bowel anastomosis timing (typically after HIPEC to avoid HIPEC exposure to anastomosis)
Document drain placement sites for postoperative management

Billing Tips

Cytoreductive surgery (CRS) does not have a single CPT code. It is billed as the sum of each individual resection performed. Common components: 58950 (pelvic tumor resection), 49200-49201 (excision of peritoneal implants, retroperitoneal tumor), 44139 (mobilization of splenic flexure), 44005 (enterolysis), bowel resection codes, and organ resection codes as applicable. Document each resection as a separately billable procedure.
HIPEC (hyperthermic intraperitoneal chemotherapy) is billed with 96549 (unlisted chemotherapy injection procedure) at most centers, or Q3001/Q9955 depending on payer. Billing varies significantly by institution and payer. Confirm with your billing and compliance team before coding HIPEC.
Peritoneal stripping is included within the tumor excision codes (49200-49201). Visceral resections (diaphragm stripping, liver capsule resection, splenectomy) are each separately billable. Document every organ and peritoneal surface addressed.
Completeness of cytoreduction (CC score) is a critical documentation element: CC-0 = no visible residual, CC-1 = <2 .5 cc-2=2.5-25 cc-3 mm mm, residual,>25 mm. Higher CC scores affect prognosis and should be clearly documented.
Major morbidity codes: anastomotic leak, bowel obstruction, and pleural effusion are common postoperative complications. Ensure that each complication is separately coded and documented, as they affect DRG and complication capture rates.

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