General Surgery Coding Alert

When your surgeon performs a hiatal hernia repair, you could be costing your practice $45 per procedure if you automatically assign a diaphragmatic hernia repair code. Typically, general surgeons also perform a Nissen fundoplication.

But watch out: You can't report both procedures during the same session or you'll face denials. Follow this expert advice to properly report these procedures every time.

"When a patient is described as having a hiatal hernia, it usually means that part of the stomach has herniated through the diaphragm 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.

"This hernia/disease process is usually treated with a Nissen fundoplication or Collis-Nissen and the diaphragmatic repair is included," Barone says.

Avoid denials: Do not be tempted to separately report Nissen procedures and hiatal hernia repairs. You will code the Nissen or Collis-Nissen repair based on your surgeon's documentation, and you will not separately report the hiatal hernia repair. Choose a code based on the type of repair and whether the surgeon used an open or laparoscopic approach.

For an open Nissen fundoplication, report 43324 (Esophagogastric fundoplasty [e.g., Nissen, Belsey IV, Hill procedures]), Barone advises. For a laparoscopic Nissen fundoplication, use code 43280 (Laparoscopy, surgical,esophagogastric fundoplasty [e.g., Nissen, Toupet procedures]).

Alternative: If your surgeon performs an open Collis-Nissen procedure, report 43326 (Esophagogastric fundoplasty; with gastroplasty [e.g., Collis]). For a laparoscopic Collis-Nissen surgery, you'll have to turn to an unlisted code: 43289 (Unlisted laparoscopy procedure, esophagus).

Remember: An epigastric hernia is not the same as a hiatal hernia. An epigastric hernia is usually through anterior wall fascia, above the umbilicus and below the zyphoid, says M. Tray Dunaway, MD, FACS, CSP, a surgeon, author, speaker, and coding educator with Healthcare Value Inc. in Camden, S.C. The hiatal hernia is internal, at the esophageal hiatus where the esophagus transits the chest cavity to the abdominal cavity.

Diaphragmatic HerniasWarrant Different Coding A hiatal hernia is "usually repaired as a part of a Nissen and is always bundled when a Nissen is performed," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program. "However, occasionally you do see a non-Nissen-type repair (usually traumatic diaphragmatic hernias). That's why there are both Nissen codes and diaphragmatic hernia repair codes,"she adds.

For a diaphragmatic hernia repair that does not involve a Nissen type of repair you should choose a code based on the approach your surgeon uses. Report 39520 (Repair, diaphragmatic hernia [esophageal hiatal]; transthoracic) for a transthoracic approach, or choose between 39530 (... combined,thoracoabdominal) and 39531 (... combined, thoracoabdominal,with dilation of stricture [with or without gastroplasty]), as appropriate.

Use unlisted for lap: CPT does not contain a specific code to describe laparoscopic diaphragmatic hernia repair,even with the addition of the new laparoscopic hernia repair codes this year. Therefore, to describe a procedure of this type, you must select the unlisted procedure code 39599 (Unlisted procedure, diaphragm).

Do the math: "CPT 39520 -- a pure hernia repair -- is probably rarely done" by a general surgeon, Barone cautions. If you report 39520 automatically, you could be forfeiting deserved reimbursement. You'll earn $935.93 for 39520 based on the Medicare Physician's Fee Schedule (the unadjusted fee for 39520, 25.95 RVUs times the 2009 conversion rate of $36.0666). However, if your surgeon performed a laparoscopic Nissen fundoplication with the hiatal hernia repair, and you code it properly using 43280, you'll receive $981.73 (the unadjusted fee for 43280, 27.22 RVUs times the conversion rate).

"A careful review of the surgeon's pre- and postoperative diagnosis(s) and preoperative history is often key to CPT coding these procedures properly," Barone says.

Surgeons usually perform a Nissen or similar esophageal repair when the patient has some type of esophageal disease, such as gastroesophageal reflux disease (GERD), "which may be associated with esophageal shortening, stricture formation, or the development of Barrett's esophagus/disease (pathologic mucosal changes in the distal esophagus)," he adds.

Some typical diagnoses you might see in your surgeon's documents in this case would be stricture and stenosis of the esophagus (530.3, Stricture and stenosis of esophagus), Barrett's esophagus (530.85, Barrett's esophagus), and GERD (530.81, Esophageal [gastroesophageal] reflux).

Alternatively: When your surgeon performs a "pure" diaphragmatic repair, you might see notations in the operative report diagnoses associated with a congenital diaphragmatic abnormality (commonly seen in infants/children) or a recent/distant prior history of usually blunt abdominal trauma.

"A diaphragmatic hernia associated with a recent history of trauma is often approached through the abdomen, for the abdominal contents can be safely 'pulled back' into the abdomen from the chest, for no adhesions have usually formed yet," Barone explains.

In this case, for the diaphragmatic hernia (including esophageal hernia, paraesophageal hernia and hiatal hernia) repairs you might see diagnoses such as diaphragmatic hernia (551.3, Diaphragmatic hernia with gangrene; 552.3, Diaphragmatic hernia with obstruction; 553.3, Diaphragmatic hernia), congenital hernia (756.6, Anomalies of diaphragm), and traumatic diaphragmatic hernia (862.0, Injury to diaphragm without open wound or 862.1, Injury to diaphragm with open wound).