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General Surgery Coding Alert

Bill Nissen Separately From Other Anti-reflux Procedures

- Published on Sun, Oct 01, 2000
Nissen fundoplication is one method general surgeons use to treat gastroesophageal reflux disease (GERD) when it is caused by a hiatal hernia.

There are other hiatal hernia repair CPT codes, however, and if the operative report is unclear or the coder is unaware of how the procedures relate to each other, two procedures may be inappropriately coded and billed when in fact only one (usually, the Nissen) was performed.

Repair of hiatal hernias and Nissen fundoplication should not be billed together because both procedures are performed to achieve the same goals, through the same incision: moving the stomach back through the diaphragmatic hiatus, repairing the hiatal hernia, and compensating for the dysfunctional esophageal sphincter to correct the reflux.

Many general surgery coders, however, may be unaware of the relationship between the Nissen and the hiatal hernia repair, and the problem may be compounded by operative reports that describe two or more procedures (for example, anti-reflux procedure and hiatal hernia repair, or Nissen fundoplication and hiatal hernia repair).

Additionally, if the surgeon performs a paraesophageal hiatus hernia repair, the word paraesophageal may be omitted from the operative note, which could have important coding and reimbursement consequences if the coder does not read through the procedure notes carefully to determine what the surgeon did.

Why the Procedures Are Performed

GERD is a digestive disorder that affects the lower esophageal sphincter (LES), which functionally separates the esophagus and the stomach. Individuals with GERD experience heartburn (acid indigestion) because the malfunctioning LES allows the stomachs contents to flow back or reflux into the esophagus. In most cases, the condition can be treated with medication, but sometimes surgery is required.

One cause of GERD is hiatal hernia, which occurs when the upper part of the stomach moves up into the chest through a small opening in the diaphragm, known as the diaphragmatic hiatus. This condition allows conflicting pressures between the chest and the abdomen to induce additional reflux.

Hiatal hernias usually do not require treatment; however, they may be complicated by reflux esophagitis (530.11) or severe GERD. In addition, if the hiatal hernia involves strangulation of the fundus of the stomach, it is known as a paraesophageal hiatal hernia (see box on page 84), a serious surgical condition requiring immediate attention.

Once the reason for the GERD is identified by performing esophagoscopy, a biopsy may or may not be taken (43200, esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]; or 43202, with biopsy, single or multiple). A surgical treatment may be recommended to patients with severe GERD and significant complications of reflux or to patients who wish to avoid lifelong pharmaceutical treatment.

How to Code Hiatal [...]

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