Hepatic Resection
4712047130wRVU: 55.76 — Right hepatic lobectomy (segments V-VIII)47125wRVU: 51.71 — Left hepatic lobectomy (segments II-IV)47122wRVU: 57.99 — Trisegmentectomy (extended right or left hepatectomy)76940wRVU: 0.0 — Intraoperative ultrasound (if used)
[Colorectal liver metastasis / HCC / cholangiocarcinoma / NET liver metastasis / benign hepatic lesion], [right / left lobe / segments X-X]
Same
[Right hepatectomy / Left hepatectomy / Segmentectomy, segments X-X / Wedge resection], [open / laparoscopic / robotic]
[Attending name], MD
[Fellow/Resident name]
General endotracheal. Arterial line. CVP kept low (target <5 blood cell during loss minimize mmhg) p parenchymal saver.< to transection.> Patient presents with [colorectal liver metastasis / HCC / hilar cholangiocarcinoma / NET metastasis] involving [right lobe / segments V-VI]. [Preoperative volumetry: FLR [X]% (adequate) / PVE performed [date]; FLR increased to [X]%.] [Staging CT demonstrates [X] lesion(s) [X] cm, no extrahepatic disease.] Margins anticipated clear. Risks including hepatic insufficiency, bile leak, hemorrhage, and liver failure discussed. Consent obtained. Intraoperative ultrasound [confirmed lesion location / revealed [X] additional lesion(s)]. No extrahepatic disease. [Margin adequate ([X] cm) / close margin at segment [X] addressed with [additional wedge / ablation].] Liver [normal parenchyma / cirrhotic / background steatosis]. The patient was positioned supine. A [right subcostal / bilateral subcostal / midline] incision was made. The abdomen was explored; no peritoneal implants. The liver was mobilized by dividing the falciform, triangular, and coronary ligaments. None [Right lobe / Segments X-X / Wedge resection specimen] to pathology with orientation sutures [X] mL [Jackson-Pratt drain at cut surface / None] Patient taken to surgical ICU / floor in stable condition.
Intraoperative ultrasound confirmed [lesion location and margins / no satellite lesions].
[RIGHT HEPATECTOMY:] The right hepatic artery was identified, clipped, and divided. The right portal vein was suture-ligated and divided. The line of demarcation [appeared / was marked with electrocautery]. The right hepatic vein was dissected at the IVC and [controlled with a vascular stapler / suture-ligated].
Parenchymal transection was performed along the [right hepatic / Cantlie's line] using [CUSA / Harmonic scalpel / Kelly-clamp fracture / LigaSure] technique. Intrahepatic bile ducts and vessels were controlled with [clips / suture ligation / vascular staplers] as encountered. [Pringle maneuver applied for [X] minutes total warm ischemia.]
The specimen was removed. The resection surface was inspected. [Bile leak tested with saline under pressure / green dye / cholangiogram; no leak.] Argon beam coagulator used on cut surface for hemostasis. [Fibrin sealant applied.]
A [closed-suction drain was placed near the cut surface.] Fascia closed with running [0-PDS]. Skin closed. Patient tolerated the procedure well.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Colorectal liver metastasis / HCC / cholangiocarcinoma / NET], [right lobe / segments ***]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Right hepatectomy / Left hepatectomy / Segmentectomy, segments *** / Wedge resection]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; arterial line; low CVP strategy; cell saver
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [colorectal liver metastasis / HCC / NET] involving ***. FLR ***%. [PVE performed ***.] Staging: no extrahepatic disease. Risks including hepatic insufficiency, bile leak, hemorrhage discussed. Informed consent obtained.
FINDINGS: Intraoperative US confirmed lesion at ***. [Additional lesion found: ***.] No extrahepatic disease. Margins clear at *** cm. Background liver [normal / cirrhotic / steatotic].
DESCRIPTION OF PROCEDURE:
Patient supine. [Right subcostal / bilateral subcostal] incision. Abdomen explored; no peritoneal implants. Liver mobilized. IOUS confirmed lesion and margins. [RIGHT HEPATECTOMY: Right hepatic artery clipped and divided; right portal vein suture-ligated; demarcation marked; right hepatic vein controlled with vascular stapler.] Parenchymal transection along [Cantlie's line / right hepatic] with [CUSA / Harmonic scalpel / Kelly-clamp fracture]. Intrahepatic vessels and ducts controlled with clips/suture ligation. [Pringle *** min.] Specimen removed. Cut surface inspected; no bile leak on saline test. Argon beam hemostasis. [Fibrin sealant applied.] [JP drain placed.] Fascia with 0-PDS; skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: [Right lobe / Segments *** / Wedge] to pathology with orientation
COMPLICATIONS: None
DRAINS: [JP drain at cut surface / None]
DISPOSITION: Patient to [SICU / floor] in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Laparoscopic hepatectomy
Minor resections (wedge, left lateral sectionectomy) are well-suited to laparoscopy. Document port placement, energy device used for transection, and specimen extraction method. Same CPT codes.
HCC in cirrhotic liver
Document Child-Pugh and MELD score. FLR requirements are higher in cirrhosis (>40% vs. >20% for normal liver). Portal hypertension (splenomegaly, varices) increases bleeding risk; document assessment.
Charting Tips
- Document Couinaud segments resected, as this drives CPT selection
- State CVP management strategy (low CVP reduces parenchymal bleeding)
- Note Pringle maneuver use and total warm ischemia time
- Document bile leak test method and result at end of case
- Orient specimen for pathology; mark at least one margin with suture
- FLR percentage should be in the note for major resections
Billing Tips
- Bill 47120 for partial hepatectomy / wedge resection (17.50 wRVU, 90-day global). Bill 47122 for trisegmentectomy (37.78 wRVU). Bill 47125 for left hepatic lobectomy (32.66 wRVU). Bill 47130 for right hepatic lobectomy (37.78 wRVU). Code selection is based on the extent of resection. Document exactly which segments are removed.
- Couinaud segment-based resection: document which segments (I-VIII) are removed. Right hepatectomy = segments V, VI, VII, VIII. Left hepatectomy = segments II, III, IV. Extended right = V-VIII + segment IV. Accurate segment documentation drives accurate CPT selection.
- Intraoperative ultrasound (IOUS) is separately billable as 76940 when used for tumor localization during the procedure. Document its use and findings explicitly.
- Portal vein embolization (PVE) performed prior to major resection to induce contralateral hypertrophy is a separate, prior procedure (37243) and does not affect the hepatectomy coding.
- 90-day global: postoperative biliary leak management, drain manipulation, and clinic visits are bundled. ERCP for biliary leak requires interventional billing but the surgical consultation component is included in the 90-day global.