# Migration Nissen



## LTibbetts (Nov 6, 2009)

I posted this in the Gastro forum and didn't get any response. I was wondering if anyone could please take a look at this for me and tell me what they think...


This is the first Nissen revision for me. I don't know if it is just me but it seems that there is much more going on here. Please read the op note below and let me know if you think that I am going in the right direction:

Post op dx: 
1 hiatal hernia
2 migration of nissen fundoplication

Procedure: Laparoscopic hiatal hernia repair

"Once the trocar was intraperitoneal, the abdomen was infiltrated with carbon dioxide to a pressure of 15mmHg. The previous subxiphoid trocars ite was injected with Marcaine and opened with a #11 blade. The obturator to a 5mm bladeless trocar was used to create a tract thru which the Nathonson retractor was placed. The left lobe of the liver was elevated, and the Nathonson was secured on the bookwalter arm. The previous trocar sites were all injected with Marcaine. A Babcock was used to protract the stomach toward the feet and laterally. Adhesions were taken down between the right crus and the esophagus using the Gyrus as well as sharp dissection. Dissection was carried out anteriorly. A large portion of the stomach was herniated on the left side. The stomach was retracted down with a Babcock, and adhesions into the chest were taken down primaryily with the Gyrus. Extensive adhesiolysis was undertaken until the stomach was completely back down in the abdominal cavity. Some adhesions were taken down from the left crus as well. Attention was then turned back to the right crus. The tacking suture of the wrap to the right crus was divided with scissors. Dense adhesions were then tediously taken down but ultimately this was accomplished leaving the wrap intact. Once the wrap was completely back down into the abdomen along the right side, attention was then turned to closing the hernia defect. A small deserosalized area on the anterior part of the stomach was oversewn with 2-0 silk sutures. The hiatus was then closed...."

What I came up with is 43280 and I am not completely comfortable with that either. I think that there is more here to code but I am not sure what it is. Is it the lysis of all of the adhesions? I thought that that was incident to the surgery itself. Do I just add a -22? Please help with this one...


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## mjewett (Nov 9, 2009)

*Nissen revision*

I come up with code 43280. Lysis of adhesions is not separately billable. Unless the op report states the surgery was unusually complicated, due to the adhesions, or something to that that effect. Then you might be able to use mod 22. Otherwise it's probably not billable.


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## LTibbetts (Nov 10, 2009)

That's what I had initially come up with as well, but after re-review of the op note and some more research, my co-worker and I respectively came up with two other options:
39599 or 43289. Any input on either of these? I am inclined to go with the 39599 code. If you do not agree, can you tell me why and explain please? I could really use some help with this one.


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## mjewett (Nov 11, 2009)

*Nissen*

Using the unlisted codes, and submitting the op report is a good option. If you are using code 39599 to represent hiatel hernia repair, I believe hiatal hernia repair is inclusive to the esophagogastric fundoplasty. 

To look that up on the NCCI edits I looked up the open nissen code 43324, and the open hiatal hernia repair code, 39502.  Per NCCI 39502 is bundled with code 43324.  I looked it up that way b/c there is no CPT code for laparoscopic hiatal hernia repair. I believe if there was a laparoscopic code the same logic would be used for determining if inclusive or not.  

So I agree, use unlisted and let the insurance price it out, just make sure they don't pay you less than at least the RVU for code 43280. You know how payers are.....


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