tci General Surgery Coding Alert - 2000 Issue 10

Bill Nissen Separately From Other Anti-reflux Procedures

Nissen fundoplication is one method general surgeons use to treat gastroesophageal reflux disease (GERD) when it is caused by a hiatal hernia. There are other hiatal hernia repair CPT codes, however, and if the operative report is unclear or the coder is unaware of how the procedures relate to each other, two procedures may be inappropriately coded and billed when in fact only one (usually, the Nissen) was performed. Repair of hiatal hernias and Nissen fundoplication should not be billed together because both procedures are performed to achieve the same goals, through the same incision: moving the stomach back...

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