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Billing code 43520: PyloromyotomyMedicare rate & RVUs

Reports surgical splitting of the pyloric muscle, typically to relieve gastric outlet obstruction from infantile hypertrophic pyloric stenosis.

CMS RVU26DEffective Oct 1, 2026109 payment localities93 Medicare services in 2024

Medicare pays $681.04 for 43520 nationally in a facility.

Medicare rate · 43520

Pyloromyotomy

Swap in your local Medicare rate.

Work RVUs
11.01
Total RVUs
20.39
Global days
090

National rate · 2026

$681.04

Facility setting, before claim adjustments.

See every locality for 43520 → · Billed by an NP, PA or therapist? →

Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.

On this page 10 sections
  1. Medicare rate
  2. What 43520 covers
  3. By payment locality
  4. Rate map
  5. How it’s calculated
  6. Payment rules
  7. Similar codes
  8. Related codes
  9. Billing questions
  10. Sources

What 43520 covers

This operation divides the thickened pyloric muscle to relieve narrowing at the stomach outlet while preserving the inner lining. It is most often performed by a pediatric surgeon for an infant with hypertrophic pyloric stenosis, in a hospital operating room. The code describes the pyloromyotomy service, not a gastric incision or a pyloric reconstruction.

Report it when the operative record supports incision of the pyloric muscle for the documented condition. The code has a 90-day global period, including the day-before preoperative visit and 90 days of related postoperative care. When multiple procedures are performed in the same session, Medicare pays the highest-valued procedure in full and applies the standard reduction to the others. Modifier 50 is inappropriate for this code. An assistant at surgery may be paid; co-surgeon payment requires supporting documentation, and team surgery is not permitted.

This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.

Where 43520 pays more and less

The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.

109 of 109 payment localities

43520 office and facility rates by payment locality
Payment localityOfficeFacility
AlabamaUnavailable$611.54
Alaska*Unavailable$834.81
ArizonaUnavailable$660.24
ArkansasUnavailable$603.09
AtlantaUnavailable$705.33
AustinUnavailable$683.06
BakersfieldUnavailable$670.29
Baltimore/Surr. CntysUnavailable$725.90
BeaumontUnavailable$654.71
BrazoriaUnavailable$660.45

43520 rates by state

Office rate range in each state. Select a state to see its payment localities.

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Local rates. Clear comparisons.

Hover or focus a tile to see its rate range. Select it to open the state’s fee schedule.

View every state and territory as a table
43520 office rate range by state
State / territoryOffice rate rangeLocalities
AKNo published base rate1
ALNo published base rate1
ARNo published base rate1
AZNo published base rate1
CANo published base rate29
CONo published base rate1
CTNo published base rate1
DCNo published base rate1
DENo published base rate1
FLNo published base rate3
GANo published base rate2
GUNo published base rate1
HINo published base rate1
IANo published base rate1
IDNo published base rate1
ILNo published base rate4
INNo published base rate1
KSNo published base rate1
KYNo published base rate1
LANo published base rate2
MANo published base rate2
MDNo published base rate3
MENo published base rate2
MINo published base rate2
MNNo published base rate1
MONo published base rate3
MSNo published base rate1
MTNo published base rate1
NCNo published base rate1
NDNo published base rate1
NENo published base rate1
NHNo published base rate1
NJNo published base rate2
NMNo published base rate1
NVNo published base rate1
NYNo published base rate5
OHNo published base rate1
OKNo published base rate1
ORNo published base rate2
PANo published base rate2
PRNo published base rate1
RINo published base rate1
SCNo published base rate1
SDNo published base rate1
TNNo published base rate1
TXNo published base rate8
UTNo published base rate1
VANo published base rate2
VINo published base rate1
VTNo published base rate1
WANo published base rate2
WINo published base rate1
WVNo published base rate1
WYNo published base rate1

How the 43520 rate is calculated

Each of 43520’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.

How the rate is built · 43520

RVUs × geographic indexes × conversion factor

Swap in your local Medicare rate.

Work 11.01Practice expense 6.44Malpractice 2.94

20.3900 adjusted RVUs×$33.4009 conversion factor=$681.04

All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.

Payment rules and modifiers for 43520

43520 has a 90-day global period: related visits in that window are included in the surgery payment.

CMS payment indicators · 43520

Pyloromyotomy

RuleCMS valueWhat it means
Global period090Major surgery: the day before, the day of, and 90 days after are included.
Multiple procedures2Standard reduction: highest-valued procedure at 100%, others at 50%.
Bilateral (modifier 50)0The 150% bilateral adjustment doesn’t apply.
Assistant at surgery (80/81/82/AS)2Paid.
Co-surgeons (62)1Permitted with supporting documentation.
Team surgery (66)0Not permitted.
Professional/technical0Physician service: no professional/technical split.
Split (54/55/56)0.09/0.81/0.10Share of the payment for pre-op, the procedure itself, and post-op care.

Global surgery period · 43520

Pyloromyotomy

90-day global period ends

Dec 30, 2026

Covers Sep 30, 2026 through Dec 30, 2026 (92 days, including the day before surgery).

Visit on Oct 31, 2026

Day 30 of the 90-day post-op period: related follow-up care is included in the surgical payment.

  • 24 Unrelated E/M visit by the same physician
  • 79 Unrelated procedure (starts its own global period)
  • 58 Staged, more extensive, or therapy procedure that was planned
  • 78 Unplanned return to the operating room for a related complication
SurgeryVisit
Sep 23, 2026Jan 10, 2027

Pre-op dayGlobal period

What modifiers do to the payment

Modifier 51 · payment effect

With and without the modifier

43520 without 51 · national facility

$681.04

Pyloromyotomy

43520-51 · Second procedure: 50%

$340.52

When this isn’t the highest-valued procedure in the session, Medicare pays 50% of its fee schedule amount (the highest is paid at 100%).

When to use modifier 51

43520 compared with similar codes

Compare codes

43520 vs 43800 vs 43659 vs 43500: national Medicare rates

Swap in your local Medicare rate.

  • 43520
    Pyloromyotomy · 11.01 wRVU
    —
  • 43800
    Pyloroplasty · 15.04 wRVU
    —
  • 43659
    · 0 wRVU
    —
  • 43500
    Gastrotomy · 12.47 wRVU
    —

How to choose

43800Pyloroplasty
Use for pyloric reconstruction or enlargement; 43520 is for incision of the pyloric muscle to relieve stenosis.
43659Unlisted laps px stomach
This is an unlisted laparoscopic stomach procedure code. It may be relevant when pyloromyotomy is performed laparoscopically rather than through an open approach.
43500Gastrotomy
43500 describes a gastrotomy service involving an opening in the stomach; 43520 targets the pyloric muscle.

Codes related to 43520

Related codes aren’t interchangeable: bill the code that matches the service performed.

Codes related to 43520
CodeHow it relatesNational office range
Used instead
43800PyloroplastyPyloroplasty reconstructs or enlarges the pylorus rather than splitting its muscle.No office rate
43659Unlisted laps px stomachUnlisted laparoscopic stomach procedure code that may be relevant to a laparoscopic approach.No office rate
43820GastrojejunostomyGastroenterostomy provides a bypass in selected cases rather than incising the pyloric muscle.No office rate

43520 billing questions

How is this different from pyloroplasty?

Pyloromyotomy splits the pyloric muscle to relieve stenosis; pyloroplasty surgically enlarges or reconstructs the pylorus. Choose based on the operation documented, not simply the presence of gastric outlet narrowing.

Can this code be used for a laparoscopic pyloromyotomy?

The code describes pyloric muscle incision. For a laparoscopic approach, check the applicable coding guidance for reporting the service, which may involve an unlisted laparoscopic code.

Are routine postoperative visits separately reported?

Related postoperative care during the 90-day global period is included. The global period also includes the day-before preoperative visit.

Should modifier 50 be appended for bilateral work?

No. CMS identifies bilateral adjustment as inappropriate for this code.

What documentation supports reporting this service?

The operative report should identify the pyloric muscle incision and the clinical indication, such as hypertrophic pyloric stenosis. It should distinguish the procedure from a pyloroplasty or an incision of the stomach.

Where these rates come from

FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.

CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027

Show the CMS file lines behind this rate
RVUs for 43520PPRRVU2026_Oct_nonQPP.csv, line 5,261 (RVU26D)

Open CMS sourceHow we calculate rates

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