AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2016 Issue 2; Ask the Editor
Esophageal Lengthening Collis Gastroplasty with Nissen Fundoplication and Hiatal Hernia
The patient had surgery due to symptomatic gastroesophageal reflux and hiatal hernia. The surgeon entered the pleural cavity via thoracotomy, and a large combined sliding and paraesophageal hiatal hernia was identified. The fundus was reduced into the abdomen and sutures were placed; the esophagogastric junction failed to reduce beneath the diaphragmatic hiatus without undue tension. An esophageal lengthening Collis gastroplasty was performed in combination with the Nissen fundoplication. The gastroplasty lengthened the esophageal tube by 5 cm and a 3 cm fundoplication was constructed and secured to the tube. The fundoplication was reduced below the diaphragm and remained without tension; it was secured to the undersurface of the diaphragm with sutures. Sutures were passed through the diaphragm around the circumference of the hiatus and the posterior crural sutures were tied. Would the hernia repair be coded separately or is it inherent to the esophageal lengthening and fundoplication? What are the ICD-10-PCS procedure code assignments? ...
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Article Overview
This premium article reviews a surgical scenario involving gastroesophageal reflux disease and hiatal hernia management with esophageal lengthening and fundoplication. It is aimed at coders and billers who need to understand how the procedure is characterized for reporting and how the diagnosis coding piece is approached in the context of the operative note.
Why This Topic Matters
Procedural reports involving overlapping upper gastrointestinal and hiatal hernia work can be difficult to interpret for accurate coding. Understanding the scope of the operative description helps determine what is documented, what is bundled, and what diagnosis coding considerations are relevant.
What You Will Learn
- How the operative scenario is structured from a coding perspective
- The relationship between the surgical components described in the case
- General diagnosis-coding considerations associated with the encounter
- How questions of separate reporting versus inherent work arise in this type of case
Who Should Read This
- Medical coders
- Coding auditors
- Revenue cycle staff
- Physician documentation reviewers
- General surgery coding specialists
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