General Surgery Coding Alert

Look to -unlisted- code for laparoscopic hiatal hernia repairs.

You should never report hiatal hernia repair and Nissen fundoplication together or you-ll face miscoding denials. Instead, you will bundle the hernia repair to the same-session Nissen procedure. Read on for expert advice on the specifics of coding for these procedures.

Most typically, you-ll find that your general surgeon will perform a Nissen fundoplication rather than a less-involved hiatal hernia repair.

What to look for: During both hernia repair and fundoplication, the surgeon moves the stomach back down into the abdomen and sutures the defect in the diaphragm by narrowing the size of the diaphragmatic hiatus.

Only during the Nissen procedure, however, will the surgeon additionally wrap part of the fundus of the stomach around the esophagus. This creates a "valve" that allows food to reach the stomach from the esophagus but prevents reflux back to the esophagus.

"The stomach is reduced back into the abdomen, the enlarged diaphragmatic hiatus is reduced by suture, and the anti-reflux -valve- is established by the Nissen fundoplication," explains M. Tray Dunaway, MD, FACS, CSP, a general surgeon and an educator with Healthcare Value Inc. in Camden, S.C. Nissen procedures will always include hiatal hernia repair.

"I would say the Nissen fundoplication is the most common surgical procedure to treat gastroesophageal reflux disease (GERD)," Dunaway adds. The Nissen procedure, especially via laparoscopic approach, carries faster recovery times and costs less to perform than the other standard procedure (Belsey Mark 4), he says.

For an open fundoplasty you should select 43324 (Esophagogastric fundoplasty [e.g., Nissen, Belsey IV, Hill procedures]), says Sandra Jongebreur, CPC-GENSG, CPC, CPC-H, PCS, FCS, billing manager for Raafat Z. Abdel-Misih, MD and Joseph J. Bennett, MD in Wilmington, Del.

When your surgeon instead performs a more typical laparoscopic Nissen fundoplasty, you should report 43280 (Laparoscopy, surgical, esophagogastric fundoplasty [e.g., Nissen, Toupet procedures]), Jongebreur adds.

Special note: If your surgeon begins a laparoscopic procedure and must convert to an open procedure, you should report only the successful open procedure. Also note that "the hernia repair is included in the fundo-plasty and you should not report it separately," Jongebreur cautions.

When selecting a code to describe hiatal hernia repair only, you must pay careful attention to the approach the surgeon uses. You will either select 39520 (Repair, diaphragmatic hernia [esophageal hiatal]; transthoracic) for a transthoracic approach, or choose between 39530 (-combined, thoracoabdominal) and 39531 (-combined, throacoabdominal, with dilation of stricture [with or without gastroplasty]), as appropriate.

Tip: Expect to see most repairs of this type coming from thoracic surgeons. This makes sense because 39520 and 39530/39531 involve either transthoracic or thoracoabdominal approach, respectively, while the open Nissen procedure (43324) uses a transabdominal approach.

CPT does not contain a specific code to describe laparoscopic hiatal hernia repair. Therefore, to describe a procedure of this type, you must select the unlisted procedure code 39599 (Unlisted procedure, diaphragm), Jongebreur explains.

A paraesophageal hernia is a far more serious condition than a regular hiatal hernia, and you must learn how coding differs for these repairs. To identify a paraesophageal hernia, search the operative report for documentation that describes migration and potential strangulation of the fundus of the stomach.

For open paraesophageal repair, you should report 39502 (Repair, paraesophageal hiatus hernia, transabdominal, with or without fundoplasty, vagotomy, and/or pyloroplasty, except neonatal). Note that this is the only hiatal hernia repair (other than the hernia repair described in the Nissen procedure) that uses only an abdominal approach.

Pay attention: While performing a Nissen, the surgeon may encounter an enlarged diaphragmatic hiatus and subsequently reduce the hiatus size. You should not consider this a paparaesophageal repair, and you should code for only the Nissen procedure.

For a laparascopic paraesophageal repair, you must resort once again to 39599 because CPT does not contain a specific code to describe this procedure.