General Surgery Coding Alert

Nissen fundoplication is one method general surgeons use to treat gastroesophageal reflux disease (GERD) when it is caused by a hiatal hernia.

There are other hiatal hernia repair CPT codes, however, and if the operative report is unclear or the coder is unaware of how the procedures relate to each other, two procedures may be inappropriately coded and billed when in fact only one (usually, the Nissen) was performed.

Repair of hiatal hernias and Nissen fundoplication should not be billed together because both procedures are performed to achieve the same goals, through the same incision: moving the stomach back through the diaphragmatic hiatus, repairing the hiatal hernia, and compensating for the dysfunctional esophageal sphincter to correct the reflux.

Many general surgery coders, however, may be unaware of the relationship between the Nissen and the hiatal hernia repair, and the problem may be compounded by operative reports that describe two or more procedures (for example, anti-reflux procedure and hiatal hernia repair, or Nissen fundoplication and hiatal hernia repair).

Additionally, if the surgeon performs a paraesophageal hiatus hernia repair, the word paraesophageal may be omitted from the operative note, which could have important coding and reimbursement consequences if the coder does not read through the procedure notes carefully to determine what the surgeon did.

Why the Procedures Are Performed

GERD is a digestive disorder that affects the lower esophageal sphincter (LES), which functionally separates the esophagus and the stomach. Individuals with GERD experience heartburn (acid indigestion) because the malfunctioning LES allows the stomachs contents to flow back or reflux into the esophagus. In most cases, the condition can be treated with medication, but sometimes surgery is required.

One cause of GERD is hiatal hernia, which occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm, known as the diaphragmatic hiatus. This condition allows conflicting pressures between the chest and the abdomen to induce additional reflux.

Hiatal hernias usually do not require treatment; however, they may be complicated by reflux esophagitis (530.11) or severe GERD. In addition, if the hiatal hernia involves strangulation of the fundus of the stomach, it is known as a paraesophageal hiatal hernia (see box on page 84), a serious surgical condition requiring immediate attention.

Once the reason for the GERD is identified by performing esophagoscopy, a biopsy may or may not be taken (43200, esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]; or 43202, with biopsy, single or multiple). A surgical treatment may be recommended to patients with severe GERD and significant complications of reflux or to patients who wish to avoid lifelong pharmaceutical treatment.

How to Code Hiatal Hernia Repairs

There are three procedures that may be involved in any hiatal hernia repair (not including paraesophageal hernia, see below), but two of these, 39520 (repair, diaphragmatic hernia [esophageal hiatal]; transthoracic); and 39530 (combined, thoracoabdominal), typically are performed by thoracic surgeons. General surgeons are more likely to perform a Nissen fundoplication (43324, esophagogastric fundoplasty [e.g., Nissen, Belsey IV, Hill procedures]), which uses a transabdominal approach.

The repair of the hiatal hernia involves moving the stomach back down into the abdomen and suturing the defect in the diaphragm by narrowing the size of the diaphragmatic hiatus.

To counteract the defective LES, the surgeon may create a one-way external esophageal valve by wrapping part of the fundus of the stomach around the esophagus. This anti-reflux procedure, known as Nissen fundoplication or fundoplasty, allows food to reach the stomach from the esophagus but prevents reflux back to the esophagus.

According to the Coders Desk Reference, when the procedure is performed for hiatal hernia repair, it may include a sutured tightening of the junction of the diaphragmatic crura behind the esophagus, in other words, moving the stomach back into the abdomen and repairing the hiatus.

You wouldnt do a Nissen fundoplication without closing the esophageal hiatus, says M. Trayser Dunaway, MD, FACS, a general surgeon in Camden, S.C., adding that since the Nissen involved an abdominal incision, any sliding hiatal hernia repair through the same incision is incidental.

Laparoscopic Nissen fundoplasty, which now is performed more frequently than open Nissens, is coded 43280 (laparoscopy, surgical, esophagogastric fundoplasty [e.g., Nissen, Toupet procedures]). If the surgeon has to convert the laparoscopic Nissen to an open procedure, only 43324 (the open procedure) can be billed.

Although Medicares national Correct Coding Initiative (CCI) doesnt bundle 43324 or 43280 with 39520 and 39530, these procedures normally would not be billed together because it would be unusual for the general surgeon, who in any case is less likely to use a thoracic approach, to perform two separate approaches (abdominal for the Nissen, thoracic or thoracoabdominal for the hernia repair). In addition, because the Nissen includes repair of the diaphragmatic hiatus, such claims, even if paid by local Medicare carriers, may be questioned during an audit. Most private payers also do not pay separately for both procedures.

Note: Nissen fundoplication may be performed for reasons other than hiatal hernia, such as perforation of esophagus.

Coding for Bundled Procedures

In addition to the sliding hiatal hernia described above, on occasion an individual may have a paraesophageal hernia. The open repair that typically is performed to fix this type of hernia is coded 39502 (repair, paraesophageal hiatus hernia, transabdominal, with or without fundoplasty, vagotomy, and/or pyloroplasty, except neonatal) and is the only hiatal hernia repair (other than the hernia repair described in the Nissen procedure) that uses only an abdominal approach.

A paraesophageal hernia is a far more serious condition than a regular hiatal hernia, but because of the abdominal approach, coders may confuse the conditions and the procedures performed to correct them.

This procedure, however, is performed when an individuals fundus becomes strangulated in the diaphragmatic hiatus and requires emergency treatment. It cannot be billed along with a Nissen procedure because the 39502 code descriptor clearly states that fundoplasty is included in the procedure. The two procedures also are bundled in the CCI.

While performing a Nissen, some surgeons may encounter an enlarged diaphragmatic hiatus and subsequently reduce the hiatus size. This should not be considered a paraesophageal repair, and only the Nissen should be billed.

In any event, because the two procedures (Nissen and repair) are bundled, even if a paraesophageal repair is inappropriately claimed, the CPT code (39502) includes fundoplasty and, therefore, the Nissen could not be billed.

Note: Not all patients with paraesophageal hernia require fundoplication.

Laparoscopic Paraesophageal Hernia Repair

Although some surgeons have performed para-esophageal hernia repair laparoscopically, there is no CPT code for this procedure, and no consensus about how it should be coded.

If a laparoscopic Nissen also was performed, some surgeons use code 43280 (for the Nissen) and 43289 (unlisted laparoscopic procedure, esophagus) for the hernia repair. Because the open repair bundles the Nissen, these procedures, performed laparoscopically, likely could not be billed separately even though the description of 43289 both in CPT and Coders Desk Reference makes no mention of hernia repair.

For laparoscopic esophageal hiatus hernia repairs performed alone, one option frequently suggested is attaching modifier -22 (unusual procedural services) to the existing open code (39502). However, Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist in North Augusta, S.C., argues that this modifier is used for more difficult, time-consuming procedures, and the laparoscopic repair may not fall into that category. Even more important, Callaway-Stradley says, is the fact that using modifier -22 limits the amount of extra payment that can be paid (to no more than 20 to 30 percent, in most situations).

Instead, Callaway-Stradley recommends using an unlisted code because the constraints on what may be charged are less and surgeons may have more leverage in setting their own fees. Even here, there are two choices 43289 and 39599 (unlisted procedure, diaphragm). Callaway-Stradley says use the unlisted diaphragm code because it is more specific than its laparoscopic equivalent.

Because the code is unlisted, the operative note and a cover letter explaining the procedure and the request for special reimbursement should accompany the claim, Callaway-Stradley says.

Finally, as with the Nissen, if the paraesophageal repair was begun laparoscopically and then converted to open, this should be noted in the operative report, and only the open procedure should be billed.

Coding Repeat Procedures

Sometimes, the fundus wrap around the esophagus may become herniated, and the procedure needs to be repeated. In such cases, the procedure code used (43324 or 43280) would be claimed again, possibly with modifier
-52 (reduced services) if much of the procedure does not need to be repeated.

Typical Reflux Disorder Diagnosis Codes Nissen 150.4 malignant neoplasm of middle third of esophagus 150.5 malignant neoplasm of lower third of esophagus 150.8 malignant neoplasm of other specified part of esophagus 150.9 malignant neoplasm of esophagus" " unspecified 151.0 malignant neoplasm of cardia 197.8 secondary malignant neoplasm of other digestive organs and spleen 230.1 carcinoma in situ of esophagus 230.2 carcinoma in situ of stomach 530.11 reflux esophagitis 530.2 ulcer of esophagus 530.3 stricture and stenosis of esophagus 530.81 esophageal reflux 552.3 diaphragmatic hernia with obstruction 553.3 diaphragmatic hernia without mention of obstruction or gangrene 750.3 congenital tracheoesophageal fistula" " esophageal atresia and stenosis 750.4 other specified congenital anomalies of esophagus 756.6 congenital anomaly of diaphragm 783.3 feeding difficulties and mismanagement 787.2 dysphagia 789.06 abdominal pain" epigastric 789.07 abdominal pain generalized 789.09 abdominal pain other specified site 862.22 esophagus injury without mention of open wound into cavity 908.1 late effect of internal injury to intra-abdorninal organs 908.6 late effect of certain complications of trauma 909.3 late effect of complications of surgical and medical care 925.2 crushing injury of neck 997.4 digestive system complications V47.3 other digestive problems Paraesophageal Hiatus Hernia Repair 551.3 diaphragmatic hernia with gangrene 552.3 diaphragmatic hernia with obstruction 553.3 diaphragmatic hernia 750.6 congenital hiatus hernia