AHA Coding Clinic® for HCPCS - 2021 Issue 3; Ask the Editor
Hybrid transoral incisionless fundoplication (TIF®)
A patient with gastric reflux presented for a hybrid transoral incisionless fundoplication (TIF®). The procedure began in the operating room where a laparoscopic hiatal hernia repair was performed. During the hernia repair, the overlaying fat pad of the gastro-esophageal junction (GEJ) was excised to reduce bulk between the GEJ and fundus in preparation for the TIF® portion of the procedure. The patient was then taken to the GI lab where the fundoplasty was performed endoscopically. The scope was passed into the GEJ, entered the stomach, and was then retroflexed. A device was inserted for the valve reconstruction and incisionless fundoplication. What is the correct CPT code(s) for a hybrid TIF® where a hiatal hernia is repaired laparoscopically and the fundoplication is performed endoscopically during the same surgical encounter? ...
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Article Overview
This premium coding article explains the CPT coding considerations for a hybrid transoral incisionless fundoplication (TIF®) case in which a hiatal hernia is repaired laparoscopically and the fundoplication portion is completed endoscopically. It is relevant to coders, billers, and revenue cycle staff working with gastroenterology and surgical procedures, especially when multiple techniques are used during one operative session. The article focuses on procedure identification and code selection for the combined operative approach.
Why This Topic Matters
Hybrid anti-reflux procedures can involve multiple service locations and techniques in a single encounter, making accurate CPT assignment important for clean claims and consistent reporting.
What You Will Learn
- How the hybrid TIF® procedure is structured across surgical and endoscopic portions
- Which CPT coding considerations apply to a combined hiatal hernia repair and endoscopic fundoplication encounter
- How the article frames code selection for a hybrid anti-reflux procedure in one operative session
- How the procedure setting and technique affect coding review
Who Should Read This
- Medical coders
- Coding auditors
- Billers
- Revenue cycle staff
- Gastroenterology coding professionals
- Surgery coding professionals
Codes Discussed
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