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Policy No: 104

Originally Created: 02/01/2015

Section: Surgery

Last Reviewed: 02/01/2019

Last Revised: 02/01/2019

Approved: 02/07/2019

Effective: 03/01/2019

The policy applies to physicians, other qualified health care professionals and facilities.

Definitions

Bariatric Surgery

Surgical procedures performed on the stomach or intestines to promote significant and sustained weight loss for patients who are morbidly obese. It is a treatment of last resort after conservative measures have failed.

Gastropexy

Suture of the esophagus or stomach to the hiatus for fixation.

Hiatal Hernia

The hiatus is an opening in the diaphragm where the distal esophagus passes through to enter the abdomen. A hiatal hernia occurs when the stomach bulges up into the thorax (chest) through the hiatus. There are four types of hiatal hernias:

Type I 

A hiatal hernia (type I) occurs when there is a protrusion of the upper part of the stomach and esophagus (gastroesophageal junction) into chest. This is the most common type (about 95%) of all hiatal hernias. This is also called a sliding hiatal hernia. A hiatal hernia of this type may also contain the upper segment of a sleeve gastrectomy or the ‘pouch' of a gastric band or gastric bypass. Additionally, if less than 50% of the stomach is located above the diaphragm, this is still considerd a type I hiatal hernia and is not considered a paraesophageal hiatal hernia.

Type II 

A paraesophageal hiatal hernia (type II) occurs when the esophagus and gastroesophageal junction remain in their normal location but a part of the stomach, typically the fundus, protrudes through the hiatus next to the esophagus into the chest. These ‘pure' type II paraesophageal hiatal hernias seldom occur.

Type III 

A paraesophageal hiatal hernia (type III) occurs when there is a combination of both type I and II hiatal hernias, when the stomach and esophagus protrude into the chest AND the fundus of the stomach lies above the gastroesophageal junction and rotates along its long axis in a rolling or twisting fashion, referred to as an organo-axial torsion. A "giant" hiatal hernia is a subset of type III hiatal hernias and defined when greater than 50% of the stomach has protruded into the chest. The majority of paraesophageal hernias are type III. However, all types of paraesophageal hiatal hernias make up about 5% of hiatal hernias but account for most of the hiatal hernia complications. The complications are primarily due to interference with the blood flow from the left gastric artery to the twisted fundus.

Type IV 

A paraesophageal hiatal hernia (type IV) occurs when a structure other than the stomach, such as the large intestine, small intestine or omentum protrudes through the hiatus into the chest.

Hiatal hernias are very common and most are asymptomatic and require no treatment. Symptomatic hiatal hernias are generally related to gastroesophageal reflux disease (GERD) or true paraesophageal types of hiatal hernia.

Policy Statement

Coding

Current Procedural Terminology (CPT®) states: "Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided."

CPT codes 43280 (laparoscopic), 43325 43327 43328 (open) are the correct codes to report for a esophagogastric fundoplasty. Per CPT and NCCI, the esophagogastric fundoplasty includes any associated type I hiatal hernia repair; which is not reported separately.

CPT codes 43281 43282 (laparoscopic), 43332 43333 43334 43335 43336 43337 (open) can only be reported for a paraesophageal hiatal hernia repair. A paraesophageal hiatal hernia of type II, III, or IV must be clearly documented. The esophagogastric fundoplasty, if also performed is an included component. It is not acceptable to use the paraesophageal hernia repair codes to report a type I hiatal hernia repair procedure.

There is not a specific code to describe laparoscopic or open type I hiatal hernia repair or gastropexy procedure. 

Edits

When a major esophagogastric procedure (e.g. codes codes 43279, 43280, 43283, 43284, 43285, 43320, 43325, 43327, 43328, 43330, 43331, 43338) or bariatric surgery (e.g., codes 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848) is performed and a hiatal hernia repair or gastropexy (e.g., codes 39599, 43281, 43282, 43289, 43332, 43333, 43334, 43335, 43336, 43337 49659) is also performed, the hiatal hernia / gastropexy procedure is considered an included component of the major esophagogastric / bariatric surgery, even if the bariatric surgery was not billed or is denied as not a covered benefit of the member's contract. Separate reimbursement will not be made for the hiatal hernia / gastropexy procedure regardless of modifier appended.

References

None

Cross References

Associated Claims

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.