General Surgery Coding Alert

Question: I'm having an issue with an insurance company overpayment for a laparoscopic diaphragmatic hernia repair. We're billing 39599, but they're saying we should use 49659. Who is correct?

Florida Subscriber

Answer: CPT 2010 introduced two new codes for lap paraesophageal or diaphragmatic hernia repairs, so you should select the correct code from these, as of Jan. 1:

• 43281 -- Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh

• 43282 -- ... with implantation of mesh.

Check the date: If you're talking about a past claim denial from prior to Jan. 1, you have several issues to consider to determine the correct code. First, you might remind the insurer that 49659 (Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy) refers to defects in the abdominal wall, but your surgeon repaired a defect in the diaphragm.

Second, you should consider that CPT generally places codes in the digestive system chapter when the procedure is a lap approach. For instance, CPT placed the new lap paraesophageal hernia repair codes 43281 and 43282 in the esophagus section rather than the diaphragm section (even though the open code is in the diaphragm section). Using this logic, you could argue that you should have used an unlisted lap code from either the diaphragm section (39599,Unlisted procedure, diaphragm) or the esophagus section (43289, Unlisted laparoscopy procedure, esophagus).

Finally, remember that insurance companies actually get to make up their own rules. If they want you to bill a lap diaphragmatic hernia repair using 49659 and they will put that guidance in writing, you should bill the service that way. Sometimes when you ask for the instruction inwriting, the insurer will back down and accept the coding you've submitted. Other times they will send you  nstructions in writing. Either way, the insurer will pay you, and that's what you want.