General Surgery Coding Alert

New open codes acknowledge hiatal hernia repair, too.

Open or laparoscopic, through chest or abdominal wall, with or without hiatal hernia repair, with or without mesh ... these are the various ways your surgeon might perform an esophagogastric fundoplasty. And these are the factors you'll need to take into account when you try to pick the proper code(s) from among nine new choices in CPT 2011.

Let our experts show the way with four how-to tips for paraesophageal hiatalhernia repair and fundoplication coding for 2011.

Tip 1: Understand Pathophysiology

"When a patient is described as having a hiatal hernia, it usually means that part of the stomach has herniated through the opening in the diaphragm [esophageal hiatus] into the chest and is usually associated with esophageal reflux disease," according to Gary W. Barone, MD, a physician and associate professor at the University of Arkansas for Medical Sciences in Little Rock.

The hernia repair typically involves the surgeon reducing the stomach back into the abdomen and suturing the enlarged diaphragmatic hiatus, explains M. Tray Dunaway, MD, FACS, CSP, a general surgeon and an educator with Healthcare Value Inc. in Camden, S.C.

During the fundoplication procedure, such as Nissen, the surgeon additionally wraps part of the fundus (top) of the stomach around the esophagus and sutured in place. This creates a "valve" that allows food to reach the stomach from the esophagus but prevents reflux back to the esophagus.

"I would say the Nissen fundoplication is the most common surgical procedure to treat gastroesophageal reflux disease (GERD)," Dunaway adds. Watch for gastroplasty: Sometimes the esophagus is shortened and the surgeon can't reduce the hernia. "The surgeon might perform a gastroplasty, forming a tube of stomach to effectively elongate the distal esophagus," Dunaway says. An example of such a procedure is a Collis gastroplasty.

Tip 2: Use 43332-43337 for Open Hiatal Hernia Repair With/Without Fundoplication

CPT 2011 introduces the following codes for hiatal hernia repair that will give you more coding options based on the specifics of your surgeon's work:

• 43332 -- Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis
• 43333 -- ...with implantation of mesh or other prosthesis
• 43334 -- Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or other prosthesis
• 43335 -- ...with implantation of mesh or other prosthesis
• 43336 -- Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; without implantation of mesh or other
• 43337 -- ...with implantation of mesh or other prosthesis.

You'll be able to more adequately describe the procedure performed with these additional codes for paraesophageal hiatal hernias that define approach, as well as the use of mesh, according to Myra P. Anderson, CPC, CCAT, CPAT, coding educator with Ochsner Health System.

First identify the approach -- laparotomy, thoracotomy, or thracoabdominal incision " to zero in on the proper code pair.

Then pick the appropriate code based on whether your surgeon documents the implantation of mesh or other prosthesis.

Old way: Located in the CPT esophagus section, codes 43332- 43337 replace deleted codes from the diaphragm section: 39502 (Repair, paraesophageal hiatus hernia, transabdominal, with or without fundoplasty, vagotomy, and/or pyloroplasty, except neonatal), 39520 (Repair, diaphragmatic hernia [esophageal hiatal]; transthoracic), 39530 (... combined, thoracoabdominal), and 39531 (... combined, thoracoabdominal, with dilation of stricture [with or without gastroplasty]).

New opportunity: When your surgeon performed a fundoplication with hiatal hernia repair prior to Jan.1, you had to use now-deleted fundoplication code (43324, Esophagogastric fundoplasty [e.g., Nissen, Belsey IV, Hill procedures]) but couldn't additionally capture the hernia repair with 39502 or 39520-39531. Now codes 43332-43337 account for both the fundoplasty and hernia repair -- and the pay shows it.

For example: If your surgeon performed a transthoracic hiatal hernia repair with fundoplication and mesh placement, you'd have earned $1276.49 for 43324 in 2010, but you'll earn $1,399.15 for 43335 in 2011. If you'd reported the hernia repair (39520) alone in 2010, you'd have earned only $942.50. (Pricing based on Medicare physician fee schedule national facility RVUs [2010 for deleted codes] and conversion factor 33.9764.)

Tip 3: Open 'Fundoplication Only' Earns 43327-43328

If the surgeon performs an open fundoplasty procedure without the hernia repair, you should select one of the following CPT 2011 codes:

• 43327 -- Esophagogastric fundoplasty partial or complete; laparotomy
• 43328 -- ... thoracotomy.

As with new codes 43332-43337, you can distinguish the codes based on the surgical approach.

Old way: Remember that CPT 2011 deletes code 43324, and a new text note directs you to 43327-43328. The new codes pay $825.97 and $1213.30, respectively (based on Medicare physician fee schedule national facility amount using conversion factor 33.9764).

Tip 4: Add +43338 for Open Esophageal Lengthening

If the surgeon performs an open esophageal lengthening in addition to a fundoplasty procedure described by any of the new codes 43327-43328 or 43333-43337, you should additionally report the following new CPT 2011 code to capture the additional work:

• +43338 -- Esophageal lengthening procedure (e.g., Collis gastroplasty or wedge gastroplasty) (List separately in addition to code for primary procedure).

Old way: Prior to the addition of +43338, you would have reported an open Collis-Nissen procedure as 43326 (Esophagogastric fundoplasty; with gastroplasty [e.g.,Collis]). CPT 2011 deletes 43326 and directs coders to the new fundoplasty codes plus +43338.