Summary & Overview

CPT 43641: Highly Selective Parietal Cell Vagotomy with Pyloroplasty

CPT code 43641 represents a surgical intervention — a highly selective parietal cell vagotomy combined with repair or enlargement of the pylorus, with optional gastrostomy. Nationally, this code is used to bill for targeted vagal denervation of acid-secreting gastric mucosa alongside a pyloric procedure intended to improve gastric emptying and reduce ulcer recurrence in select patients. The procedure is relevant to gastroenterology and general surgery service lines and has implications for surgical case mix, inpatient resource use, and post-operative care pathways.

Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical context for the procedure, expected sites of service, and an outline of typical billing modifiers and payer considerations where available. The publication summarizes common coding practices, potential billing scenarios, and related service considerations that affect authorization, site-of-service determination, and claims processing. Data not available in the input for associated taxonomies, specific ICD-10 diagnoses, related codes, and payer-specific policy language is noted where applicable. The document is intended for revenue cycle professionals, surgical and gastroenterology clinicians, and policy analysts who need a clear operational summary of CPT code 43641 and its role in clinical billing workflows.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare43641CPTGastric SurgeryVagotomyPyloroplastySurgical BillingInpatient SurgeryGastroenterologyOperative Procedure

Billing Code Overview

CPT code 43641 describes a highly selective parietal cell vagotomy with pyloroplasty, a surgical procedure in which the surgeon selectively severs vagal nerve fibers supplying the parietal cells of the stomach and repairs or widens the pylorus to improve gastric emptying; a gastrostomy may or may not be created. This procedure is a surgical gastric vagotomy with pyloric repair.

Service type: Open abdominal surgical procedure aimed at reducing gastric acid secretion and improving gastric outflow.

Typical site of service: Inpatient or outpatient surgical suite depending on clinical indications and patient factors; frequently performed in hospital operating rooms with possible postoperative inpatient observation.

Clinical & Coding Specifications

Clinical Context

A 58-year-old male with a long history of peptic ulcer disease refractory to medical therapy presents with recurrent gastric outlet obstruction and persistent epigastric pain despite optimized proton pump inhibitor therapy. Endoscopy shows scarring and pyloric narrowing with healed but recurrent ulceration. The surgical team elects to perform a highly selective, parietal cell vagotomy with pyloroplasty to decrease acid secretion while improving gastric emptying. The operative plan includes intraoperative assessment of pyloric patency and optional placement of a gastrostomy tube if postoperative decompression or enteral access is anticipated.

Preoperative workflow includes history and physical, medication reconciliation (notably anticoagulants), informed consent documenting the rationale for vagotomy and pyloric repair, and anesthesia evaluation. Intraoperative documentation should specify extent of vagal division (highly selective/parietal cell), technique of pyloric repair or pyloroplasty, whether a gastrostomy was created, estimated blood loss, and any complications. Postoperative care includes monitoring for delayed gastric emptying, infection, pain control, and instructions for diet advancement and follow-up.

Coding Specifications

Modifier	Description	When to Use
`00`	No modifier — default state	Use when no specific modifier applies to the service.
`11`	Office or other outpatient visit for evaluation and management	Use when the service includes a significant, separate E/M on the same day as the procedure (report per payer rules).
`22`	Increased procedural services	Use when the work, time, or complexity of the procedure is substantially greater than typical and documented accordingly.
`23`	Unusual anesthesia	Use when general anesthesia is not used because of medical condition requiring local/monitored anesthesia care for an otherwise normally anesthetized procedure.
`26`	Professional component	Use when only the surgeon’s professional component is billed separate from hospital technical charges (rare for operative codes billed by hospital).
`50`	Bilateral procedure	Use when the procedure is performed bilaterally (not typical for this CPT; included if applicable to anatomic interpretation).
`51`	Multiple procedures	Use when additional distinct procedures are performed during the same operative session and multiple-procedure reduction rules apply.
`52`	Reduced services	Use when the service is partially reduced or not completed as documented.
`53`	Discontinued procedure	Use when the procedure is terminated due to extenuating circumstances or patient condition prior to completion.
`54`	Surgical care only	Use when only the surgeon’s intraoperative and immediate postoperative care is billed, and another clinician bills pre/post-op care.
`55`	Postoperative management only	Use when only postoperative care is billed by the furnishing surgeon.
`56`	Preoperative management only	Use when only preoperative care is billed by the furnishing surgeon.
`62`	Two surgeons	Use when two surgeons of different specialties work together as primary surgeons; documentation must reflect distinct, concurrent work.
`63`	Procedure performed on infants less than 4 kg	Use when the patient meets weight criteria and the modifier is required by the payer.

Taxonomy Code	Specialty	Notes
`408600000X`	General Surgery	Surgeons who commonly perform vagotomy and pyloroplasty procedures.
`208800000X`	Gastroenterology	May perform diagnostic endoscopy and perioperative evaluation; not typically the operating surgeon for open vagotomy.
`207W00000X`	Colorectal Surgery	Occasionally involved when complex foregut/pyloric pathology overlaps subspecialty care.
`207L00000X`	Thoracic Surgery	In centers where combined foregut approaches require thoracic surgical expertise for upper abdominal access.
`363L00000X`	Transplant Surgery	Rarely involved for complex redo foregut operations in specialized centers.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`K27.9`	Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation	Peptic ulcer disease refractory to medical therapy is a common indication for vagotomy and pyloric repair.
`K29.70`	Gastritis, unspecified, without bleeding	Chronic gastritis may coexist with peptic ulceration influencing surgical decision-making.
`K31.84`	Gastroparesis	Delayed gastric emptying may prompt pyloroplasty in addition to vagotomy to improve gastric outflow.
`K91.2`	Postintestinal bypass syndrome	Surgical history leading to obstructive or ulcerative complications sometimes necessitates pyloric repair or vagotomy in revision procedures.
`K22.2`	Achalasia of cardia	Though primarily an esophageal disorder, complex foregut motility disorders can influence surgical planning for gastric emptying procedures.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`43235`	Esophagogastroduodenoscopy, flexible, diagnostic, with or without collection of specimen(s) by brushing or washing	Preoperative diagnostic endoscopy to evaluate ulcer disease, pyloric stenosis, or sample mucosa prior to definitive surgery.
`43830`	Pyloroplasty, any technique; without vagotomy	Alternative or adjunctive procedure focused on pyloric repair when vagotomy is not performed.
`43644`	Subtotal gastrectomy with gastroduodenostomy (Billroth I)	More extensive gastric surgery performed when disease requires resection rather than vagotomy and pyloroplasty.
`49440`	Insertion of gastrostomy tube, open, without repair of leak or fistula	Used when a gastrostomy is created during the procedure for decompression or enteral access; CPT `43641` notes the surgeon may or may not create a gastrostomy.
`92960`	Cardiopulmonary resuscitation (CPR)	Included as an example of an emergent intraoperative intervention if cardiopulmonary arrest occurs (report per guidelines).