Cytoreductive Surgery and HIPEC
4919049255wRVU: 12.25 — Omentectomy (if performed)38100wRVU: 19.06 — Splenectomy (if performed as part of cytoreduction)44120wRVU: 20.3 — Small bowel resection (if required)96547wRVU: 6.53 — Intraoperative HIPEC, first 60 minutes (6.53 wRVU, add-on to primary CRS code)96548wRVU: 3.0 — Intraoperative HIPEC, each additional 30 minutes (3.00 wRVU, add-on to 96547)
[Appendiceal mucinous neoplasm / colorectal peritoneal metastasis / ovarian cancer / mesothelioma] with peritoneal carcinomatosis
Same
Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), [completeness of cytoreduction CC-0 / CC-1]
[Attending name], MD
[Fellow/Resident name]
General endotracheal. Arterial line, central venous access. Cell saver. Epidural [if placed].
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.
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].
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].
HIPEC: Following cytoreduction and prior to bowel anastomosis [/ after anastomosis per institutional protocol], the abdomen was irrigated with hyperthermic chemotherapy solution. [Mitomycin C [X] mg/m2 administered at 42 degrees C for 90 minutes — standard regimen for colorectal and appendiceal histologies. / Cisplatin [X] mg/m2 with doxorubicin [X] mg/m2 at 42 degrees C for 60-90 minutes — for mesothelioma. / Oxaliplatin [X] mg/m2 at 42-43 degrees C for 30 minutes — Elias protocol; note PRODIGE 7 (Lancet Oncol 2021) did not demonstrate survival benefit for oxaliplatin HIPEC in colorectal peritoneal metastases; agent and protocol should reflect institutional multidisciplinary decision.] A [closed / open Coliseum] technique was used. Inflow and outflow temperatures were monitored; intra-abdominal 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.
None
All resected specimens to pathology with individual labeling
[X] mL
[Jackson-Pratt drains x2-3 in pelvis and right upper quadrant / None]
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 at 42 degrees C x 90 min / Cisplatin *** mg/m2 + doxorubicin *** mg/m2 at 42 degrees C x 60-90 min / Oxaliplatin *** mg/m2 at 43 degrees C x 30 min], [closed / Coliseum] technique; inflow and outflow temps monitored; intra-abdominal temp 41-43 degrees C. 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
.TODAYVariants
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 and rationale — two protocols exist (anastomosis before HIPEC vs. after HIPEC); document which was used and state the reason. This is institution-specific; there is no universal standard.
- Document drain placement sites for postoperative management
Billing Tips
- Cytoreductive surgery has no single CPT code. Bill each component separately. Intra-abdominal tumor excision uses 49186-49190 (replaced deleted codes 49203-49205 effective 2025), selected by the sum of the maximum length of each tumor/cyst excised: 49186 sum <=5 cm (21.45 wRVU); 49187 5.1-10 cm (27.93 wRVU); 49188 10.1-20 cm (33.15 wRVU); 49189 20.1-30 cm (39.00 wRVU); 49190 >30 cm (48.75 wRVU). Most CRS cases qualify for 49189 or 49190. Document each tumor/cyst diameter in the operative note. Do not apply 49186-49190 to tumors arising directly from a separately reported organ.
- Intraoperative HIPEC via temporary catheter (open Coliseum or closed technique) is billed with 96547 (first 60 minutes, 6.53 wRVU, add-on to primary CRS code) and +96548 for each additional 30 minutes (3.00 wRVU). These codes were added to the CPT code set in 2024 specifically for intraoperative HIPEC and replaced the prior practice of using unlisted code 96549. Time-based rules apply: 96547 requires at least 31 minutes; 96548 requires 76+ total minutes (at least 16 min beyond the first 60). Document HIPEC start and end time in the operative note. CPT 96446 (0.37 wRVU) applies only when a permanent implanted peritoneal port is in place and is not appropriate for intraoperative HIPEC via temporary catheter.
- Peritoneal stripping is included within 49186-49190. Visceral organ resections are each separately billable: omentectomy 49255 (12.25 wRVU), splenectomy 38100 (19.06 wRVU), small bowel resection 44120 (20.30 wRVU), colectomy 44140-44160. GYN oncology interaction: for primary or interval ovarian cancer debulking, use 58950-58956/58960 (GYN debulking codes) rather than 49186-49190, as those codes capture the peritoneal component for primary disease. CPT 58957 (recurrent ovarian/tubal/peritoneal debulking without lymphadenectomy) was deleted effective January 1, 2025. Per AMA CPT Assistant (February 2025), 49186-49190 is now appropriate for recurrent GYN malignancies without lymphadenectomy. The parenthetical note for 49186-49190 excludes reporting them with 58943, 58950-58956, 58958, or 58960 — but does not exclude recurrent-disease scenarios. Confirm with your institutional billing team for GYN cases at the diagnostic code level.
- Completeness of cytoreduction (CC score) is a critical documentation element: CC-0 = no visible residual, CC-1 = <2.5 mm residual, CC-2 = 2.5-25 mm, CC-3 = >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.
General coding reference. Verify with your institution’s billing department before submitting claims.