Hepatic Resection
4712047130wRVU: 55.76 — Alternative primary code — right hepatic lobectomy, segments V-VIII (55.76 wRVU); mutually exclusive with 47120/47122/4712547125wRVU: 51.71 — Alternative primary code — left hepatic lobectomy, segments II-IV (51.71 wRVU); mutually exclusive with 47120/47122/4713047122wRVU: 57.99 — Alternative primary code — trisegmentectomy, extended right hepatectomy (segments IV-VIII) (57.99 wRVU); mutually exclusive with 47120/47125/4713037243wRVU: 11.45 — Portal vein embolization (if performed prior to resection as a staged procedure; billed by IR)
[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 mmHg) to minimize blood loss during parenchymal transection. [Cell saver with leukodepletion filter — use leukodepletion filter for all malignant cases (HCC, CRLM, cholangiocarcinoma) to reduce theoretical tumor cell reinfusion risk; cell saver without filter is appropriate for benign lesions only.]
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.
Intraoperative ultrasound confirmed [lesion location and margins / no satellite lesions].
[RIGHT HEPATECTOMY:] The right hepatic artery was identified, [suture-ligated and / clipped and] divided. The right portal vein was suture-ligated and divided. The line of demarcation [appeared / was marked with electrocautery]. The liver was mobilized further; retrohepatic inferior vena cava exposed and short hepatic veins (accessory hepatic veins) individually ligated and divided. The right hepatic vein was dissected at the IVC and [controlled with a vascular stapler / suture-ligated and divided].
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 [continuously / intermittently (15 min clamp / 5 min release cycles)] 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.
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.
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 [with leukodepletion filter for malignant cases]
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 suture-ligated and divided; right portal vein suture-ligated and divided; demarcation marked; retrohepatic IVC exposed; short hepatic veins individually ligated and divided; 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 [continuous / intermittent **** min on / **** min off].] 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 vary by hepatic background — normal liver greater than or equal to 20-25%; chemotherapy-injured liver (e.g., post-FOLFOX for CRLM) greater than or equal to 30%; cirrhotic liver greater than or equal to 40%. Portal hypertension (splenomegaly, varices) increases bleeding risk; document assessment. ICG-R15 test (hepatic function reserve) is used at many centers in cirrhotic patients.
Charting Tips
- Document Couinaud segments resected, as this drives CPT selection
- State CVP management strategy (low CVP reduces parenchymal bleeding)
- Note Pringle maneuver use, technique (continuous vs. intermittent), cycle length if intermittent, and total warm ischemia time
- Document retrohepatic IVC dissection and short hepatic vein ligation for right hepatectomy — these are critical steps for safety and completeness
- 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 (38.03 wRVU, 90-day global). Bill 47122 for trisegmentectomy (57.99 wRVU). Bill 47125 for left hepatic lobectomy, segments II-IV (51.71 wRVU). Bill 47130 for right hepatic lobectomy, segments V-VIII (55.76 wRVU). These codes are mutually exclusive alternative primaries — select one based on extent of resection; do not bill them together. CPT 47120 is reported once per operative session regardless of how many non-anatomic wedge resections are performed; never bill 47120 twice for two wedge excisions at the same setting.
- 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) during hepatic resection: CPT 76940 is the wrong code — its descriptor is 'ultrasound guidance for tissue ablation' (RFA/microwave), not tumor localization during resection. The technically correct code is 76998 (intraoperative ultrasound guidance, 0.89 wRVU), but when the operating surgeon performs IOUS, Medicare and most payers bundle it into the primary hepatectomy code and will deny a separate 76998 claim. IOUS performed by a separate provider (e.g., intraoperative radiology) may be separately billable under that provider's NPI. Document IOUS use and findings in the note for clinical purposes regardless.
- 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.
General coding reference. Verify with your institution’s billing department before submitting claims.