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CMS RVU26D · Effective 2026-10-01

43520 Pyloromyotomy Medicare reimbursement rates in Kentucky

Reports surgical splitting of the pyloric muscle, typically to relieve gastric outlet obstruction from infantile hypertrophic pyloric stenosis. Compare 43520 office and facility rates across CMS payment localities in Kentucky.

Amounts below use the non-QP conversion factor for participating physicians. These are base physician payments before claim-level adjustments, not patient costs or total hospital charges.

What does Medicare pay for 43520 in Kentucky?

Kentucky has 1 payment locality in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the payment area shown below, using the same CMS release.

Office / nonfacility

No supported rate

Facility setting

$648.82

1 of 1 localities have a supported rate.

Payment area: Kentucky

One mapped payment locality.

These are locality ranges, not averages or address-specific quotes. A facility-setting amount covers the physician service; it does not include a hospital’s separate bill. Choose a locality below to inspect its calculation, compare other payment areas, or price a percentage of Medicare.

Find 43520 in your payment locality →

Digestive surgery

About 43520: Pyloric muscle incision for stenosis

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

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.

CMS billing rules for 43520

Global period
Major surgery with a 90-day global period: the day-before preoperative visit and 90 days of related postoperative care are included.
Multiple procedures
Standard multiple procedure reduction: the highest-valued procedure is paid in full and others at 50% when performed in the same session.
Bilateral procedures
Bilateral adjustment does not apply; the descriptor or anatomy makes modifier 50 inappropriate.
Assistant at surgery
Assistant at surgery may be paid.
Co-surgeons
Co-surgeons paid only with supporting documentation.
Team surgery
Team surgery not permitted.

Where the value comes from

  • Work RVU11.01 · 54%
  • Practice expense (office) RVU6.44 · 32%
  • Malpractice RVU2.94 · 14%

93

Medicare services in 2024 · #4935 by national volume

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.

43520 compared with similar codes

Office rates for Kentucky, from the same CMS release.

43800

Pyloroplasty

No office rate

Use for pyloric reconstruction or enlargement; 43520 is for incision of the pyloric muscle to relieve stenosis.

43659

Unlisted laps px stomach

No office rate

This is an unlisted laparoscopic stomach procedure code. It may be relevant when pyloromyotomy is performed laparoscopically rather than through an open approach.

43500

Gastrotomy

Exploration or biopsy

No office rate

43500 describes a gastrotomy service involving an opening in the stomach; 43520 targets the pyloric muscle.

Compare 43520 by payment locality

Find the payment area for your service address, then open its rate page for calculation inputs, release history and the percentage-of-Medicare tool. A city may cross payment-area boundaries; the ZIP lookup above helps resolve the location.

1 of 1 payment localities

Office and facility base rates · shared scale starting at $0

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How this local rate is calculated

Each RVU component is multiplied by its own geographic practice cost index (GPCI). The three adjusted components are added, then multiplied by the conversion factor. These are the inputs used for 43520 in Kentucky.

PPRRVU2026_Oct_nonQPP.csv

5,261

Code
43520
Physician work
11.01
Practice expense
6.44
Malpractice
2.94

GPCI2026.csv

55

Locality
Kentucky
Physician work
1.000
Practice expense
0.889
Malpractice
0.915
Facility calculation for 43520 in Kentucky
ComponentRVULocality factorAdjusted
Physician work11.01× 1.00011.0100
Practice expense6.44× 0.8895.7252
Malpractice2.94× 0.9152.6901
Total RVUs19.4253
Conversion factor× 33.4009

Facility rate, Kentucky$648.82

Values as parsed from CMS release RVU26D, effective 2026-10-01. The amount is rounded to the nearest cent only at the end.
Explore RVUs, geographic factors and the full formula

Facility

Facility calculation inputs
ComponentRVULocal GPCI
Work11.011
Practice expense6.440.889
Malpractice2.940.915

(11.01 × 1 + 6.44 × 0.889 + 2.94 × 0.915) × $33.4009 = $648.82

The office and facility calculations use their respective practice-expense RVUs. The facility amount here is the physician fee, not a separate hospital or facility bill.

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 indices and the applicable conversion factor. Unavailable or separately priced services are labeled rather than assigned a made-up amount.

Source: RVU26D. Effective 2026-10-01 through the day before 2027-01-01.

RVUs for 43520PPRRVU2026_Oct_nonQPP.csv, line 5,261 (RVU26D)
Geographic factors for KentuckyGPCI2026.csv, line 55 (RVU26D)
Open CMS sourceHow this rate is calculatedBuild a fee sheet