General Surgery Coding Alert

Look for deleted ‘emerging technology’ codes.

If your surgeon performs a laparoscopic procedure to place or remove a device that augments the function of the Lower Esophageal Sphincter (LES), you’ll have two new codes to describe the procedures in CPT^® 2017.

Read on for a look at the new codes, and the deleted codes they replace, to help you use them correctly beginning January 1.

Move On From Category III Codes

CPT^® 2017 deletes the following two codes:

• 0392T — Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e. magnetic band)
• 0393T — Removal of esophageal sphincter augmentation device.

These are Category III codes, which means they were temporary codes used to allow for data collection specific to emerging technology, services or procedures. Now CPT^® has accepted these procedures for placement in the Category I section in 2017 as follows:

• 43284 — Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e. magnetic band), including cruroplasty when performed
• 43285 — Removal of esophageal sphincter augmentation device.

Understand the Device and Procedures

The sphincter augmentation device is a series of magnetic beads linked by a wire that encircle the esophagus just below the LES in such a way that it can expand and contract. The device is calibrated to the appropriate diameter and magnetic resistive force for each individual patient’s needs, so that the sphincter may “open” when the patient swallows or expresses gas or vomit, but remains closed under normal conditions to halt reflux of stomach contents into the esophagus.

The laparoscopic surgical approach is to the anterior gastroesophageal junction, preserving the phrenoesophageal ligament and freeing the left crus from the posterior gastric fundus to create a tunnel between the posterior vagus nerve and the posterior esophageal wall. The surgeon then inserts and removes a sizing tool, followed by introducing the sphincter augmentation device through the posterior tunnel and securing the ends together on the anterior surface of the esophagus. If the patient has a hiatal hernia of up to 3 cm, the surgeon will repair the opening by approximating the crura with stitches.

“Because the 43284 code definition states, ‘including cruroplasty when performed,’ you should not separately bill a hiatal hernia repair code for stitching the crura to close the small hiatal hernia,” says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.

Removal is different: If the surgeon later removes the esophageal sphincter augmentation device for any reason, you should report the service as 43285.

Look for Indications and Medical Necessity

The primary indication for placing an esophageal sphincter augmentation device is Gastro-Esophageal Reflux Disease (GERD). This is a condition caused by an inadequate LES that repeatedly allows stomach acid to back-flow into the esophagus, resulting in heartburn and possibly changes to the esophageal lining that may lead to cancer.

Not first treatment: Currently, many carriers will pay for a surgical intervention for GERD only if the patient does not get adequate relief from medical therapy with proton pump inhibitors (PPIs) to reduce the production of stomach acid.

When surgery is indicated, the gold-standard has been a surgical fundoplasty such as Nissen fundoplication. This procedure involves “wrapping” a portion of the stomach around the gastric fundus to halt reflux. These tend to be fairly invasive procedures, and the down side can be that the sphincter no longer functions for escaping gas or vomit, called gas-bloat syndrome.

The esophageal sphincter augmentation device is a newer technology and procedure intended to solve the problem of LES inadequacy, and thus, GERD, without a more extensive surgical procedure and significant side effects involved with fundoplasty.

Because the augmentation device procedure is an emerging technology, insurers might not yet cover the procedure, or might have strict guidelines for patient’s to qualify.

Expert tip: As with any newly introduced technology, you might want to have your billing/coding staff talk with the equipment manufacturer representative about diagnostic indicators, and to obtain a copy of the FDA certificate, which all devices require before they can be used in the clinical setting. You might want to drop these claims to paper and send a copy of the FDA certificate with the claim to let the payer know that the procedure is not “investigational.”

Check ICD-10: You have two diagnosis codes to choose from for patients with GERD, as follows:

• K21.0, Gastro-esophageal reflux disease with esophagitis
• K21.9, Gastro-esophageal reflux disease without esophagitis.