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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