# Revision of Fundoplication code



## jdibble (Aug 1, 2019)

Our surgeon took his patient back to surgery to do a revision of a fundoplication. He removed some stitches to allow the fundoplication to open and did a dilation of the esophagus. I have CPT code 43450 for the dilation but I have no idea how to code the stitch removal. The OP note is below. If anyone has any ideas on how to code this it would be appreciated!!

Preoperative Diagnosis 
Dysphagia after partial fundoplication

Postoperative Diagnosis 
Same

Procedure Performed 
Laparoscopy, revision of partial fundoplication, upper endoscopy and sizing of esophagus with bougie dilators.

The patient was taken the operating room after induction satisfactory general endotracheal anesthesia was prepped draped in usual fashion spine position in the low lithotomy position.  His previous laparoscopy incisions were opened and trocars placed after insufflating the abdomen with a Veress needle.  Exploratory laparoscopy was performed.  There was inflammation around the hiatus which was expected and perhaps more so than expected.  The left lobe of the liver was carefully dissected off of the anterior portion of the repair and swept laterally with the liver retractor.  Dissection of some surrounding fat and omentum was performed through very dense adhesions.  This was stripped inferiorly exposing the partial fundoplication.  The right and left aspects of the fundoplication were identified.  At this point a orogastric tube was inserted to clearly identify the esophagus.  This was noted in the stomach.  Several sutures that were nearly absorbed in scar and inflammatory tissue were identified and elevated.  Each of these on the left side of the fundoplication were cut and removed allowing the fundoplication to open.  At this point upper endoscopy was performed and a wire from the Savary dilator set was placed in the stomach under direct visualization.  This was then sized from 11 to 16 mm (48 French with no resistance under visualization during laparoscopy.  Repeat endoscopy revealed that the area the fundoplication was not as tight and the scope passed easily into the stomach.  Air was aspirated from the stomach in the esophagus and the endoscope removed.  The abdomen was irrigated aspirated and desufflated after removing the trocars under direct visualization.  Three 0 Vicryl sutures were used to close the subcutaneous tissues and Steri-Strips and sterile bandages were applied.  The patient tolerated this procedure satisfactorily and returned to recovery in stable condition with all final sponge, instrument and needle counts correct.

Thank you for all answers!!
Jodi


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## unicorn80 (Aug 1, 2019)

The stitch removal wouldn't be coded as it was part of a prior procedure. An example when stitch removal would be coded is if the patient was put under anesthesia for the stitch removal. This sounds like it may need a modifier though for the stitch removal but normally is already bundled in with the code for the primary procedure. Hope this helps


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## jdibble (Aug 5, 2019)

unicorn80 said:


> The stitch removal wouldn't be coded as it was part of a prior procedure. An example when stitch removal would be coded is if the patient was put under anesthesia for the stitch removal. This sounds like it may need a modifier though for the stitch removal but normally is already bundled in with the code for the primary procedure. Hope this helps


This was a stitch removal to revise the previous surgery as the patient was having issues. The surgeon did this to alleviate his dysphagia after the surgery. Would you still consider this included in the previous surgery? This is not a normal part of the previous surgery.


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## unicorn80 (Aug 25, 2019)

From my understanding if the sutures were removed under anesthesia, other than local it would be reported but otherwise there is no code for the suture removal if local or no anesthesia was provided and is included with the E/M code. I would have thought that because the patient was returning for a revision of a previous operation and the sutures from that operation needed to be cut to allow the fundoplication to open wouldn't be reported separately because it's not like the patient was there for just the stitch removal as there was something else involved and the only way for the surgeon to do what he needed to do without any other option than to remove the sutures from the previous surgery to me sounds like it would be included as part of the primary procedure. If there was anesthesia administered which I didn't see anything mentioned about anesthesia but if there was it wouldn't have been for the stitch removal. Any anesthesia administered during a procedure would be for the procedure itself and nothing else like removing stitches.

Tip: If sutures are removed under local or no anesthesia then the service is included in the E/M code. Anything other than local anesthesia and if done by other surgeon, report CPT code 15851


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