General Surgery

A shift in paraesophageal hernia thinking changes this year’s CPT®, plus what’s new with esophagus repairs and hemorrhoids.

By Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS, CCS-P

The diaphragm repair and esophagus repair sections of CPT® underwent significant revisions for 2011. These changes reflect a shift in thinking about how paraesophageal hernia repairs should be identified, as well as changes in the way they typically are repaired.

Certified General Surgery Coder CGSC

In years past, codes to describe paraesophageal hernia repairs were classified as anatomic disorders of the diaphragm. A new understanding of paraesophageal hernia physiology has caused them to be reclassified as variants of hiatal hernias.

Hiatal Hernia Basics

A hernia occurs when an organ slips through the muscle (in this case, the diaphragm) wall that holds the organ in place. A hiatal hernia occurs when the upper part of the stomach pushes through an opening in the diaphragm, and up into the chest. This opening is called the esophageal hiatus or diaphragmatic hiatus.

There are two categories of hiatal hernias: sliding and paraesophageal.Hernia

  • A paraesophageal hernia occurs when the gastroesophageal (GE) junction remains where it belongs, but part of the stomach is squeezed up into the chest beside the esophagus. The part of the stomach that has moved into the chest cannot return to its anatomic position. There are serious risks associated with this type of hernia.
  • Hiatal hernias are considered to be “sliding” when the entire stomach, including the GE junction, slides up into the chest. It may slide back into its normal place, as well. Hernias of this type also pose risks, but the risks usually are not as acute as with paraesophageal hernias.

Codes Distinguish Repair Technique

Hiatal hernia repairs involve repairs to the diaphragm, the esophagus, or both. New codes describe treatment of paraesophageal hernia by laparotomy, thoracotomy, or thoracoabdominal approach. Each set of codes includes one code for repair without mesh or other prosthetic and one code for repair with mesh or other prosthetic:

43332  Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis

43333  Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; 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  Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; with implantation of mesh or other prosthesis

43336  Repair, paraesophageal hiatal hernia (including fundoplication), via thoracoabdominal, except neonatal; without implantation of mesh or other prosthesis

43337  Repair, paraesophageal hiatal hernia (including fundoplication), via thoracoabdominal, except neonatal; with implantation of mesh or other prosthesis

Code paraesophageal hernia repairs by laparoscopic approach with 43281 Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh or 43282 Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh (These codes were added to CPT® in 2010.).

approach

With procedures of this type, documentation should include:

  • Approach (laparotomy, thoracotomy, or both)
  • Repair of the diaphragm, esophagus, or both with return of the abdominal contents to their normal anatomic locations, if performed
  • Placement of mesh or prosthesis,
    when performed
  • Fundoplication, if performed
  • Closure

Because the descriptions of the paraesophageal hernia repair codes are so similar in wording, coders may want to highlight or underline the word(s) in each code that sets it apart from the others. For example, in code 43333, coders might highlight as follows:

43333  Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis

One glance at your CPT® book will remind you that this code is for laparotomy approach, doesn’t apply to neonates, and includes mesh repair. Don’t be afraid to write in your CPT® book so the details that set each code apart can be quickly identified.

Neonatal Repairs Code to 39503

Note that 43332-43337 should not be used for neonatal diaphragmatic hernia repairs. Such repairs still are classified as diaphragmatic hernias, and coded with 39503 Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia.

Esophagus Repairs Revised

Esophageal repair codes also underwent significant revision for 2011. Codes 43324 and 43326 have been deleted. Coders are now directed to 43327 Esophagogastric fundoplasty partial or complete; laparotomy and 43328 Esophagogastric fundoplasty partial or complete; thoracotomy to report esophagogastric fundoplasty—including the popular Nissen fundoplication—by laparotomy and thoracotomy approaches (credit armondo). These codes describe the treatment of gastroesophageal reflux by wrapping part of the proximal stomach around the distal esophagus, tightening the sphincter and also putting pressure to close the sphincter each time the stomach contracts.

Documentation for these new codes should include:

  • Approach (laparotomy or thoracotomy)
  • Plication of the stomach around the distal esophagus
  • Repair of the diaphragm, esophagus, or both with return of the abdominal contents to their normal anatomic locations, if performed
  • Closure

If the approach for one of these procedures is by laparoscopy, choose instead 43280 Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures).

Be Alert to Nissen vs. Hernia Repair Differences

Be aware that the Nissen codes (43227-43328) include repair of any hiatal hernia, and the hiatal hernia codes include any fundoplication. The reason for the procedure should drive code assignment (Nissen for GE reflux, hernia repair for hernia), but in cases where either code could be assigned appropriately, the relative value units (RVUs) are higher for the hernia repair codes. Assign these to reflect the risk and work associated with those repairs.

To illustrate proper coding, consider this sample note for a laparotomy approach to a large hiatal hernia repair, using mesh and a Nissen fundoplication performed at the same time.

This would be best coded 43333—although it would be acceptable to use 43327. You cannot report the two codes together because each includes both repair of hernia and fundoplication.

Esophageal Lengthening

When the esophagus is too short to appropriately reach through the diaphragm, it may be lengthened by making a tube of the proximal stomach. Staples are placed on each side to narrow the proximal stomach and this additional length becomes part of the esophagus. Two add-on codes, new for 2011, describe esophageal lengthening in conjunction with the fundoplasty and hernia repair codes.

+43283  Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty) (List separately in addition to codes for primary procedure)

+43338  Esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty) (List separately in addition to code for primary procedure)

Code 43283, which describes laparoscopic approach, is to be used only with 43280, 43281 Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh and 43282 Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh.

Code 43338, which does not specify an approach but would be assumed to be for open approach, may be used with open codes 43327-43337, but also may be used with laparoscopic code 43280. This is quite different from most CPT® coding rules. It is recommended that only 43283 be used with laparoscopic procedures, and 43338 be used only for open procedures because the instruction to use 43338 with 43280 may be a typographical error that will be corrected in the future.

New Codes Replace Diaphragm Repairs

With the addition of 43332-43337, codes 39502 and 39520-39531 have been deleted. The deleted codes included work that is now only rarely performed. For example, 39502 for repair of paraesophageal hernia included vagotomy and pyloroplasty at the time of the procedure because patients often presented with esophageal strictures and gastric ulcers, which would be dealt with surgically. Advances in pharmacology have made strictures much less common. Advances in technology typically allow strictures to be treated endoscopically. As a result, vagotomy and pyloroplasty are performed rarely as part of a paraesophageal hernia repair.

OP NOTE:

DIAGNOSIS: Paraesophageal hernia.

OPERATION(S):

1. Paraesophageal hernia with Veritas mesh.

2. Nissen fundoplication.

INDICATIONS: The patient has a symptomatic paraesophageal hernia. We discussed laparoscopic repair with biologic mesh and a Nissen fundoplication. She understood the risks including recurrence, bloating, dysphagia, and diarrhea, and wished to proceed.

DESCRIPTION: The patient received general endotracheal anesthesia, preoperative antibiotics, and subcutaneous heparin. She was placed in the low lithotomy position with arms tucked and all extremities well padded. She was prepped and draped in the usual sterile fashion. A laparotomy incision was made in the upper midline. We retracted the liver with a paddle liver retractor.

We moved part of the stomach that was not attached in the hiatus from the mediastinum with gentle traction. We then took down the short gastric vessels with an Autosonic scalpel. We divided the hernia sac and the gastrohepatic ligament. We then were able to reduce the entire hernia sac, which was now just attached to the gastroesophageal junction, and placed a Penrose drain around the esophagus.

We then mobilized the esophagus deep in the mediastinum until we had at least 3 cm of intra-abdominal esophagus. We closed the hiatus posteriorly with interrupted 2-0 silk sutures and buttressed it with a piece of 4-ply Veritas mesh cut in a U with the broad-based U fully covering the hiatal closure.

We then marked the posterior fundus, brought it around the esophagus, grasped a mirror image of the anterior fundus, and brought them together for our fundoplication. We placed coronal sutures from the top of the fundus to the right side of the esophagus and right crus and mesh. A similar suture was placed on the left side, and we further fixed the fundoplication to the mesh and hiatal closure where the fundoplication sat naturally.

We then closed the skin incision with 4-0 Polysorb sutures. Sterile dressings were placed, and the patient was extubated and taken to the recovery room in stable condition.

 

Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS, CCS-P, is the manager of compliance education for a large university practice group. She is the long-time consulting editor for General Surgery Coding Alert, and has presented at five AAPC national meetings.

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One Response to “General Surgery”

  1. Kathryn Evers says:

    Wouldn’t this be an in patient procedure? What would be the point or benefit of scheduling this as an out patient observation then changing it to in patient after the procedure?

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