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What’s the Word on GERD?

 Find out the latest on gastroesophageal reflux diagnosis and treatment coding.

By Rebecca M. Hovis, CPC, CPC-P, CGIC
Gastroesophageal reflux is the backward flow of the gastric contents into the esophagus due to improper functioning of the lower esophageal sphincter (also called the cardiac sphincter). Gastroesophageal reflux disease (GERD), ICD-9-CM 530.81 Esophageal reflux, is a highly variable, chronic condition characterized by periodic episodes of gastroesophageal reflux, accompanied by heartburn, which may damage the esophagus.

Coding Diagnostic Procedures

Common procedures to diagnose GERD include esophageal pH testing and impedance testing. Patients scheduled for pH and/or impedance monitoring often are tested for a 24-hour period while off any proton pump inhibitor (PPI) medication.
Reported with CPT® 91034 Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode(s) placement, recording, analysis and interpretation and 91035 Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation, esophageal pH testing measures acid reflux in the esophagus. Code 91035 specifically describes the Bravo™ pH Monitoring system, or “Bravo capsule.”
Impedance testing is similar to esophageal pH testing, but is a newer technique that measures gas or liquid reflux into the esophagus. It is useful in patients who have reflux of substances that are not acidic, and would not be detected by an esophageal pH study.
Impedance testing is reported using one of two codes, depending on the duration of testing (which should be documented in the medical record):
91037 Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation;

91038 prolonged (greater than 1 hour, up to 24 hours)

Codes 91037 and 91038 may be used alone or in combination with the esophageal pH study (91034 and 91035). In patients with refractory reflux, combined impedance and pH monitoring might provide the best strategy for evaluation of reflux symptoms.
Like the esophageal pH study, impedance testing uses a small catheter passed through the nose, into the esophagus. The catheter is attached to the recording device (worn around the patient’s waist), and the patient is asked to perform his or her regular daily activities.

Turn to 26 for Professional-only Services

A trained physician reads and interprets esophageal pH studies and/or impedance studies when they are complete. If the billing physician does not own the testing equipment, or if testing is done as an outpatient hospital procedure, bill for the test interpretation and reading only by appending modifier 26 Professional component to the appropriate testing code(s).
For example, a patient presents for outpatient impedance testing. After informed consent is obtained, the patient is placed in the sitting position. The impendence electrode is inserted by a transnasal approach and placed approximately 5 cm above the lower esophageal sphincter. The patient is released.
The next day, the physician interprets the recorded data and assigns a Johnson-DeMeester score. A reflux episode (or non-reflux, as in additional impedance testing) is defined as an esophageal pH drop below four. There are six parameters to obtain the analysis score:
1. Percent total time pH < 4
2. Percent upright time pH < 4
3. Percent supine time pH < 4
4. Number of reflux episodes
5. Number of reflux episodes ≥ 5 min.
6. Longest reflux episode (minutes)
A typical reflux patient could have a score lower than four for each parameter, for 80 percent of the 24-hour period. Acid-related and non-acid-related episodes are measured in the upright and supine positions.
In our example, the physician will report 91038-26 for her interpretation.

Treatment May Include Surgical Options

Pharmaceutical treatment for esophageal reflux usually includes proton pump inhibitors (PPIs), which are medications that decrease the amount of acid in the stomach and intestines. Based on the results of esophageal pH studies and/or impedance studies, the provider may increase PPI dosage for patients whose acid is poorly controlled. If a symptomatic patient is refluxing, but acid levels are low, the provider could consider antispasmodics or tricyclic antidepressants at low doses, which block the pain pathway from the stomach to the brain .
When the patient experiences regurgitation and acid uncontrolled by PPIs, a surgical intervention known as laparoscopic Nissen fundoplication may be necessary, says gastroenterologist Michael F. Sheffield, MD, of Gastroenterology Specialists of Oregon, P.C. The patient would need to be referred to a general surgeon or surgeon who performs the procedure.
The technique, developed by Dr. Rudolph Nissen (1896-1981), involves placating (wrapping) the upper part of the stomach (the gastric fundus) around the lower end of the esophagus and stitching it in place. This reinforces the crossing function of the lower esophageal sphincter so when the stomach contracts, it closes off the esophagus rather than squeezing stomach acids into the esophagus.
Proper coding for laparoscopic Nissen fundoplication is 43280 Laparascopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures). Be aware that a Nissen procedure may occur in addition to paraesophageal hernia repair. When this occurs, choose either 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, depending on whether the surgeon uses mesh during the repair. Do not report 43280 in addition to 43281 or 43282; both hernia repair codes bundle (include) the fundoplasty.

Open Approach Calls for Dedicated Coding

Less commonly, Nissen procedures may be performed by an “open” approach, to include 43327 Esophagogastric fundoplasty partial or complete; laparotomy to report esophagogastric fundoplasty with gastroplasty by laparotomy (stomach incision), or 43328 Esophagogastric fundoplasty partial or complete; thoracotomy to report esophagogastric fundoplasty with gastroplasty by thoracotomy (chest incision). Codes 43332-43337 describe open paraesophageal hiatal hernia repair by various approaches (laparotomy, thoracotomy, and via thoracoabdominal incision), with or without mesh implantation, and also include fundoplication, when performed. Do not report 43327 or 43328 in addition to 43332-43337.

Cite Add-on Codes for Esophageal Lengthening

In addition to fundoplasty, surgeons may perform an esophageal lengthening procedure to reverse esophageal shortening due to advanced reflux stricture or ulceration. These procedures may be performed laparoscopically (+43283 Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty) (List separately in addition to code for primary procedure)), or by an open approach (+43338 Esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty) (List separately in addition to code for primary procedure)).
When performed, report laparoscopic add-on procedure 43283 with 43280, 43281, or 43282. You may report an open esophageal lengthening procedure (+43338), when properly documented, with a laparoscopic Nissen fundoplasty (43280), or open repairs 43327-43337.
Rebecca M. Hovis, CPC, CPC-P, CGIC, has been in the health care field since 1995, when she obtained her medical receptionist certificate at Clackamas Community College Oregon City, Ore. She has been employed at Gastroenterology Specialists of Oregon, P.C. since 1997, and has been coding at the 15-practitioner office since 2008.

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