General Surgery Coding Alert

Save paraesophageal codes for stomach, other herniation.

Don’t be fooled — the vast majority of surgical hiatal hernia repairs don’t require you to use one of six CPT^® codes that include “repair, … hiatal hernia” in the code definition.

If you find that fact surprising, you need to study the following two surgical cases to guarantee that you know to how to choose the right hiatal hernia repair code — and get the right pay — for your surgeon’s work.

Bonus: To help you make sure you know your hiatal hernia “types,” read “Breakdown Sliding vs. Paraesophageal Hiatal Hernia” on page 42.

Case 1: Sliding Hiatal Hernia Repair

The surgeon performs a laparotomy to expose the hiatus, and mobilizes the gastroesophageal (GE) junction and reduces it into the abdomen. To accomplish reducing the GE junction 3 cm or more below the hiatus, the surgeon must perform an esophageal lengthening procedure. The surgeon then narrows the enlarged hiatus and constructs the fundoplication by “wrapping” and suturing the fundus over the GE junction.

Solution: You should code the case as 43327 (Esophagogastric fundoplasty partial or complete; laparotomy). You’ll also need to list +43338 (Esophageal lengthening procedure [e.g., Collis gastroplasty or wedge gastroplasty] [List separately in addition to code for primary procedure]) for the esophageal lengthening.

Here’s why: You should report Type I hiatal hernia repair with simple fundoplasty codes 43327 and 43328 (…thoracotomy), according to CPT^® Assistant, Feb. 2012. “Type I [repair] would not be reported with the paraesophageal repair codes,” the article states. 

Surprise: More than 95 percent of hiatal hernias are classified as “sliding,” according to Gary W. Barone, MD, a physician and associate professor at the University of Arkansas for Medical Sciences in Little Rock. Those are Type I hiatal hernias, and because they’re so common, they represent the majority of hiatal hernia repairs. That means you’ll use the “fundoplasty” codes, not the (esophageal) “hiatal hernia” codes for most of your surgeon’s hiatal hernia repair.

Case 2: Type II Paraesophageal Hiatal Hernia Repair

For a 55-year-old male, the surgeon performs left thoracotomy, exposes the mediastinum, and finds stomach fundus herniated through the diaphragmatic hiatus. The surgeon excises the hernia sac and reduces the stomach through the hiatus into the abdominal cavity. The surgeon then narrows the enlarged hiatus and constructs the fundoplication by “wrapping” and suturing the fundus over the GE junction without mesh placement.

Solution: “This case represents a Type II hiatal hernia repair,” says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash. Report the procedure as 43334 (Repair, paraesophageal hiatal hernia [including fundoplication], via thoracotomy, except neonatal; without implantation of mesh or other prosthesis). 

“Because the surgeon doesn’t document mesh placement, you should not bill the procedure using 43335 (… with implantation of mesh or other prosthesis),” Bucknam says.

Options: If the surgeon had used a different open approach in this case, you could choose one of the following codes:

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

·         43333 — … with implantation of mesh or other prosthesis

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

·         43337 — … with implantation of mesh or other prosthesis.

Lap is different: If the surgeon performs laparoscopic repair of paraesophageal hernia, you should choose 43281 (Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh) or 43282 (…with implantation of mesh).

“If the surgeon lengthens the esophagus during the lap procedure, also report +43283 (Laparoscopy, surgical, esophageal lengthening procedure [e.g., Collis gastroplasty or wedge gastroplasty] [List separately in addition to code for primary procedure]),” Bucknam says.