Gastroenterology Coding Alert

Question: I recently encountered two different situations with laparoscopic fundoplications: In the first case, the physician used mesh reinforcement with the fundoplication. The second was an esophagogastric myotomy with anterior fundoplication. The physician mentions, "Myotomy estimated about 5 cm long standing just above level of hiatus." How should I report these?

Mississippi Subscriber

Answer: CPT^® does not contain a code to describe separate placement of mesh along with laparoscopic fundoplasty. If the mesh placement was conducted for hernia repair along with fundoplasty, you can use 43282 (Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh). Instead if the mesh placement was conducted only to reinforce the fundoplication, you will have to use 43280 (Laparoscopy, surgical, esophagogastric fundoplasty [e.g., Nissen, Toupet procedures]). If placing the mesh added significant work to the procedure (at least 25 percent additional time or effort as compared to the average time/work for lap fundoplasty without mesh placement), you may append modifier -22 (Increased procedural services) to 43280.

Payers scrutinize modifier -22 claims carefully, and your documentation must legitimize use of the modifier. File the claim manually. Attach a separate note explaining the unusual nature of the procedure, comparing the surgery to a "typical" lap fundoplasty and explicitly noting the additional time or effort required to place the mesh and, most important, requesting increased payment.

For instance, you may write, "Due to the atypical nature of this procedure, increased risk and complexity, and the 25 percent increase in time necessary to place mesh reinforcement, we are requesting payment in the amount of 125 percent of the usual fee." 

In most cases, placement of mesh alone would probably not add enough additional work or time to report modifier -22, but in extraordinary cases it may.

In the second case, the fundoplasty is atypically associated with an esophageal myotomy, so you will have to report the CPT^® code 43279 (Laparoscopy, surgical, esophagomyotomy [Heller type], with fundoplasty, when performed). As you can see from the descriptor to 43279, the procedure includes the fundoplasty and it should not be reported separately using 43280.