Gastrectomy (Partial and Total)
4363243621wRVU: 38.54 — Total gastrectomy with Roux-en-Y esophagojejunostomy (38.54 wRVU; use for total gastrectomy with Roux reconstruction)43620wRVU: 33.19 — Total gastrectomy with simple esophagoenterostomy, loop reconstruction (33.19 wRVU; use only when Roux-en-Y is NOT performed)43631wRVU: 23.9 — Partial gastrectomy with gastroduodenostomy (Billroth I, 23.90 wRVU)38100wRVU: 19.06 — Splenectomy (if en bloc resection for cancer)
[Gastric adenocarcinoma / gastrointestinal stromal tumor / refractory peptic ulcer disease / gastric outlet obstruction], [antrum / body / fundus / entire stomach]
Same
[Partial gastrectomy with Billroth II gastrojejunostomy / Total gastrectomy with Roux-en-Y esophagojejunostomy] and [D1 / D2] lymphadenectomy
[Attending name], MD
[Resident/Fellow name]
General endotracheal. Nasogastric tube placed. Epidural [if used].
Patient presents with [gastric adenocarcinoma / GIST / refractory PUD / GOO] at the [antrum / body / GEJ]. [Staging CT: T[X]N[X]M0.] [Neoadjuvant chemotherapy completed [date] / not given.] Multidisciplinary tumor board reviewed; resection recommended with curative intent. [Nutritional optimization completed.] Risks including anastomotic leak, delayed gastric emptying, dumping syndrome, nutritional deficiency, and injury to adjacent structures discussed. Consent obtained.
[Tumor confirmed at [antrum / body]. No peritoneal implants. No liver metastases.] Margins [adequate for oncologic resection / required intraoperative frozen section: [negative].] [Lymph nodes: regional nodes sampled / D2 dissection performed.] Reconstruction [feasible / Roux limb measured and created].
The patient was positioned supine. A midline laparotomy was performed. The abdomen was explored. No peritoneal implants. No liver metastases.
[PARTIAL GASTRECTOMY, BILLROTH II:] The greater omentum was divided from the transverse colon along the avascular plane. The gastroepiploic vessels were divided. The left gastric artery was ligated at its origin. The right gastric and right gastroepiploic vessels were ligated and divided. The duodenum was divided with a [GIA / linear] stapler just distal to the pylorus. The stomach was divided proximally [4 cm proximal to the tumor / at the mid-body] with a linear stapler, removing the [distal third / distal half] of the stomach. A [2-layer hand-sewn / circular stapled] antecolic Billroth II gastrojejunostomy was created between the gastric remnant and a loop of proximal jejunum [40 cm from the ligament of Treitz]. The staple lines were checked for hemostasis. Patency confirmed.
[TOTAL GASTRECTOMY:] Greater omentum divided. Gastroepiploic and left gastric vessels ligated at origin. Spleen [preserved / included in en bloc resection]. Short gastric vessels divided. Esophagus mobilized through the hiatus. The esophagus was divided with a linear stapler [2-3 cm above the GEJ / at the level of the diaphragm]. A Roux-en-Y limb of jejunum [45-60 cm] was created. Esophagojejunostomy performed using [circular stapler [25/29 mm] / hand-sewn 2-layer technique]. Jejunojejunostomy performed [45-60 cm distal to esophagojejunostomy] with [GIA stapler / hand-sewn]. Anastomosis checked for integrity; [air leak test negative].
[D2 LYMPHADENECTOMY:] Stations [1, 3, 4, 5, 6, 7, 8a, 9, 10, 11p, 11d] dissected and submitted as labeled specimens. [For total gastrectomy: stations 1-7, 8a, 9, 10, 11p, 11d per JGCA 5th edition. Station 12a (hepatic artery proper, hepatoduodenal ligament) is included in D2 for distal gastric cancer per JGCA 2018 guidelines. The JGCA classification uses D2 and D2+ (for additional stations beyond D2); there is no JGCA D3 designation.]
Hemostasis confirmed. Closed-suction drains placed [near anastomosis]. NGT repositioned across anastomosis. Fascia closed. Skin closed. Patient tolerated the procedure well.
None
Gastric specimen (oriented with proximal and distal margins marked) to pathology. [Lymph node stations submitted individually.]
[X] mL
[Jackson-Pratt drain near anastomosis / None]
Patient taken to surgical ICU / floor in stable condition. NPO with NGT to gravity.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Gastric adenocarcinoma / GIST / refractory PUD / GOO], [antrum / body / GEJ]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Partial gastrectomy with Billroth II gastrojejunostomy / Total gastrectomy with Roux-en-Y esophagojejunostomy] and [D1 / D2] lymphadenectomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal; NGT placed
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [gastric adenocarcinoma / GIST / refractory PUD] at the [antrum / body]. [Staging: T***N***M0. Neoadjuvant chemo complete.] MTB reviewed; curative resection planned. Risks including anastomotic leak, dumping syndrome, and nutritional deficiency discussed. Informed consent obtained.
FINDINGS: Tumor confirmed at [antrum / body]. No peritoneal implants; no liver metastases. [Frozen section margins negative.] [D2 dissection performed.]
DESCRIPTION OF PROCEDURE:
Patient supine. Midline laparotomy. Abdomen explored; no metastatic disease. [PARTIAL/BILLROTH II: Greater omentum divided; gastroepiploic and left gastric vessels ligated; duodenum divided with linear stapler distal to pylorus; stomach divided proximally at ***; antecolic Billroth II gastrojejunostomy created [2-layer / circular stapled] 40 cm from Treitz; patency confirmed.] [TOTAL GASTRECTOMY: Greater omentum divided; all gastric vessels ligated; esophagus divided with linear stapler; Roux limb *** cm created; esophagojejunostomy with [circular stapler *** mm / hand-sewn 2-layer]; jejunojejunostomy *** cm distal; air leak test negative.] [D2 lymphadenectomy: stations *** submitted individually.] Drain placed near anastomosis. NGT repositioned. Fascia and skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: Gastric specimen (oriented, margins marked) to pathology. [Lymph node stations individually labeled.]
COMPLICATIONS: None
DRAINS: [JP drain near anastomosis / None]
DISPOSITION: Patient to [SICU / floor]. NPO with NGT to gravity.
Signed: .ME, .MYDEGREE
.TODAYVariants
Laparoscopic gastrectomy
Same CPT codes. Minimally invasive approach increasingly standard for gastric cancer. Document port placement, extent of resection, reconstruction technique, and extraction site. Intracorporeal vs. extracorporeal anastomosis; document which used.
Gastrectomy for bleeding peptic ulcer (emergency)
Distal gastrectomy including the ulcer base. Document hemostasis attempts prior to OR (endoscopy, angioembolization). Billroth II preferred for speed. Document ulcer location, bleeding vessel, and reconstruction.
Completion gastrectomy
For recurrent cancer or marginal ulcer after prior partial gastrectomy. Completion gastrectomy uses 43620 (simple esophagoenterostomy, 33.19 wRVU) or 43621 (Roux-en-Y, 38.54 wRVU) as the primary code depending on reconstruction. CPT 43635 is a vagotomy add-on code restricted to partial distal gastrectomy codes (43631-43634) and cannot be billed with 43620 or 43621. Document prior reconstruction type, current anatomy, and reason for completion resection.
Charting Tips
- Document extent of resection (proximal margin distance from tumor and distal division level)
- State reconstruction type explicitly (Billroth I, Billroth II, or Roux-en-Y)
- Note anastomotic integrity test (air insufflation or blue dye check)
- Document lymph node dissection extent (D1 vs. D2) and stations taken
- Minimum lymph node count: AJCC 8th edition and JGCA guidelines recommend ≥16 lymph nodes for adequate pathologic staging of gastric cancer, regardless of dissection extent. Document total node count in findings or disposition. Fewer than 16 nodes is an inadequate staging resection per current quality standards.
- For cancer, document that peritoneal washings, omentum, and nodal stations were sent
- NGT position across anastomosis should be confirmed and documented
Billing Tips
- Bill 43632 for partial gastrectomy with gastrojejunostomy (Billroth II reconstruction, 34.26 wRVU, 90-day global). Bill 43631 for partial gastrectomy with gastroduodenostomy (Billroth I, 23.90 wRVU). Bill 43620 for total gastrectomy with simple esophagoenterostomy (33.19 wRVU). Bill 43621 for total gastrectomy with Roux-en-Y esophagojejunostomy (38.54 wRVU). Code selection depends on both extent of resection and reconstruction type; document both explicitly.
- Total gastrectomy with Roux-en-Y esophagojejunostomy: bill 43621 (38.54 wRVU, 90-day global), not 43620. CPT 43620 is total gastrectomy with simple esophagoenterostomy (loop reconstruction without Roux limb). CPT 43621 specifically includes the Roux-en-Y reconstruction with its jejunojejunostomy. Using 43620 for a Roux-en-Y reconstruction systematically underbills by 5.35 wRVU per case. Document that a Roux limb was created, its length, and the esophagojejunostomy technique used.
- D1 vs. D2 lymphadenectomy does not change the primary CPT code but affects documentation. A D2 dissection adds complexity and the nodal yield should be documented. Lymph node dissection is included in the gastrectomy code.
- Concurrent splenectomy or distal pancreatectomy (en bloc for gastric cancer): bill separately. Splenectomy: 38100 (15.26 wRVU). Distal pancreatectomy: 48140 (25.66 wRVU), not 48100 (which is open pancreatic biopsy, not pancreatectomy). Document en bloc nature and oncologic rationale for each additional resection.
- 90-day global: anastomotic leak management, drain care, and clinic visits are bundled. Return to OR for anastomotic leak or hemorrhage within 90 days uses modifier -78.
General coding reference. Verify with your institution’s billing department before submitting claims.