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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