43800
No office ratePyloroplasty
Use for pyloric reconstruction or enlargement; 43520 is for incision of the pyloric muscle to relieve stenosis.
On this page
CMS RVU26D · Effective 2026-10-01
43520 Pyloromyotomy Medicare reimbursement rates in Massachusetts
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 Massachusetts.
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 Massachusetts?
Massachusetts has 2 payment localities in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the 2 payment areas shown below, using the same CMS release.
Office / nonfacility
No supported rate
Facility setting
$678.39–$727.05
2 of 2 localities have a supported rate.
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.
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 Massachusetts, from the same CMS release.
43659
No office rateUnlisted 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.
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.
2 of 2 payment localities
Metropolitan Boston →
Office / nonfacility
Unavailable
Facility
$727.05
Rest Of Massachusetts →
Office / nonfacility
Unavailable
Facility
$678.39
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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.
5,25843502,,Surgical repair of stomach,A,,25.05,10.87,NA,10.87,,6.69,42.61,42.61,0,090,0.09,0.81,0.10,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,2594350F,,Cnslng provided symp mngmnt,I,,0.00,0.00,,0.00,,0.00,0.00,0.00,9,XXX,0.00,0.00,0.00,9,9,9,9,9,9,,33.4009,09,0,99,0.00,0.00,0.00
5,26043510,,Surgical opening of stomach,A,,14.76,8.37,NA,8.37,,3.93,27.06,27.06,0,090,0.09,0.81,0.10,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,26143520,,Incision of pyloric muscle,A,,11.01,6.44,NA,6.44,,2.94,20.39,20.39,0,090,0.09,0.81,0.10,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,26243605,,Biopsy of stomach,A,,13.38,7.01,NA,7.01,,3.58,23.97,23.97,0,090,0.09,0.81,0.10,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,26343610,,Excision of stomach lesion,A,,15.93,7.54,NA,7.54,,4.07,27.54,27.54,0,090,0.09,0.81,0.10,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
5,26443611,,Excision of stomach lesion,A,,19.87,9.57,NA,9.57,,4.96,34.40,34.40,0,090,0.09,0.81,0.10,2,0,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00