CPT 43135 Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

CPT 43135: Esophageal/Hypopharyngeal Diverticulectomy via Thoracotomy

CPT code 43135 identifies an open thoracic procedure to remove a diverticulum from the hypopharynx or esophagus via thoracotomy. This surgical intervention is significant for patients with symptomatic diverticula that are not amenable to less invasive approaches and may impact hospital resource use, perioperative risk profiles, and specialist thoracic surgical services nationally. Key payers for this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.

Readers will find a concise overview of the clinical context for CPT code 43135, expected sites of service, and the kinds of benchmarks typically evaluated for high-acuity surgical procedures (such as utilization rates, length of stay, and facility-level adoption). The publication also covers payer coverage patterns and policy considerations relevant to thoracic surgical management of esophageal and hypopharyngeal diverticula. Where available, the content highlights coding nuances and related service lines that affect claims processing and facility billing.

Data not available in the input is noted where applicable, and the piece is designed to inform billing teams, health plan analysts, and clinical coders about the key attributes and national relevance of CPT code 43135 without making clinical recommendations.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare43135CPTthoracotomyesophageal surgerydiverticulectomythoracic surgeryinpatientoperative-procedure

Billing Code Overview

CPT code 43135 describes the surgical removal of a diverticulum from the hypopharynx or esophagus performed through a thoracotomy (chest incision). This procedure involves open thoracic access to locate and excise the diverticular sac and repair the esophageal or hypopharyngeal wall as indicated.

Service type: Open thoracic surgical procedure
Typical site of service: Inpatient hospital or operating room with thoracic surgical capabilities

Clinical & Coding Specifications

Clinical Context

A 68-year-old male with progressive dysphagia, regurgitation of undigested food, and chronic cough is evaluated by an otolaryngologist and thoracic surgeon. Imaging with barium swallow and CT of the chest confirms a symptomatic Zenker or mid-esophageal diverticulum with retained food and risk of aspiration. The clinical workflow includes preoperative evaluation (history, airway assessment, anesthesia consult), informed consent discussing a thoracotomy approach, preoperative labs and chest imaging, and perioperative optimization for pulmonary and cardiac comorbidities. In the operating room under general anesthesia, the thoracic surgeon performs a thoracotomy, isolates the diverticulum, excises it, and repairs the esophageal wall. Postoperative care includes chest tube management, pain control, swallow study prior to oral intake, and discharge planning with follow-up for wound care and esophageal function.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural service	Use when work or complexity substantially exceeds typical for `43135`, documented with rationale and time.
`52`	Reduced services

CPT 43113: Esophagectomy with Small Bowel or Colon Graft via Chest Incision

CPT-43124-ESOPHAGECTOMY-WITH-CERVICAL-ESOPHAGOSTOMY-NO-RECONSTRUCTION

CPT 43124: Esophagectomy with Cervical Esophagostomy, No Reconstruction

CPT-43100-CERVICAL-ESOPHAGEAL-LESION-EXCISION

CPT 43100: Excision of Cervical Esophageal Lesion

CPT-43122-PARTIAL-ESOPHAGECTOMY-ESOPHAGOGASTROSTOMY

CPT 43122: Partial Esophagectomy with Esophagogastrostomy

CPT-43118-ESOPHAGECTOMY-DISTAL-TWO-THIRDS-WITH-INTESTINAL-INTERPOSITION

CPT 43118: Distal Esophagectomy with Colonic/Small Bowel Reconstruction

CPT-43116-ESOPHAGECTOMY-WITH-INTESTINAL-GRAFT-RECONSTRUCTION

CPT 43116: Cervical Esophagectomy with Intestinal Graft

CPT-43121-TRANSTHORACIC-ESOPHAGECTOMY-DISTAL-TWO-THIRDS

CPT 43121: Transthoracic Esophagectomy, Distal Two-Thirds

CPT-43108-ESOPHAGECTOMY-NON-THORACOTOMY-WITH-BOWEL-GRAFT-RECONSTRUCTION

CPT 43108: Esophagectomy via Non-Thoracotomy with Bowel Graft Reconstruction

CPT-43130-ESOPHAGEAL-HYPOPHARYNGEAL-DIVERTICULECTOMY-CERVICAL-APPROACH

CPT 43130: Excision of Hypopharyngeal or Esophageal Diverticulum, Cervical Approach

CPT-43107-ESOPHAGECTOMY-CERVICAL-ESOPHAGOGASTRIC-RECONSTRUCTION

CPT 43107: Esophagectomy with Cervical Esophagogastric Reconstruction

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Taxonomy Code	Specialty	Notes
2080S	Thoracic Surgery	Primary specialty performing transthoracic diverticulectomy.
207L00000X	Otolaryngology	May be involved for hypopharyngeal diverticula requiring shared expertise.
207T00000X	General Surgery	May perform esophageal diverticulectomy in some centers.
2084P0800X	Thoracic Surgery - Pediatric	Rarely applicable; included when pediatric cases occur.
367A00000X	Gastroenterology	Provides diagnostic endoscopy and perioperative esophageal assessment.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`K22.3`	Diverticulum of esophagus	Primary diagnosis indicating presence of an esophageal diverticulum requiring surgical removal.
`K21.9`	Gastro-esophageal reflux disease without esophagitis	GERD can contribute to symptoms and esophageal dysfunction associated with diverticula.
`R13.10`	Dysphagia, unspecified	Common presenting symptom leading to evaluation and indication for diverticulectomy.
`J69.0`	Aspiration pneumonitis due to food and vomit	Complication of diverticulum with regurgitation and aspiration risk prompting surgical intervention.
`K22.4`	Perforation of esophagus	Potential complication to consider preoperatively or postoperatively; may alter surgical planning.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`43280`	Endoscopic, transoral esophageal diverticulectomy or myotomy	Alternative minimally invasive approach for select diverticula; may be performed instead of thoracotomy in appropriate cases.
`32551`	Tube thoracostomy, includes water seal (e.g., chest tube)	Often performed perioperatively for pleural drainage following thoracotomy.
`43110`	Excision, diverticulum or pouch of esophagus, cervical	Related cervical approach for proximal diverticula when thoracotomy is not used.
`43235`	Esophagoscopy, flexible, diagnostic, including collection of specimen	Preoperative or intraoperative diagnostic endoscopy to assess mucosa and diverticulum.
`99223`	Initial hospital care, typically 70 minutes or more	Example inpatient evaluation and management code for critically ill or complex postoperative patients.

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