On April 1, 2015 The National Correct Coding Initiative (NCCI) published a new set of code pair edits for primary bariatric surgical procedures (CPT 43644/5, 43770, 43775) and paraesophageal hernia repair with or without mesh (CPT 43281/2). A “code pair edit” eliminates, or limits, the reimbursement of two codes being billed on the same patient on the same day. More information on code pair edits can be found here. (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf).
In 2013, the Insurance Committee reported the code pair edit of primary bariatric surgery (CPT 43644, 43770, 43775) reported with fundoplication with hiatal hernia repair (CPT 43280). (http://asmbs.org/articles/insurance-committee-coding-alert-hiatal-hernia-repair-cpt-43280-may-2013) ASMBS has supported the use of CPT 43280 with the reduced work modifier (-52) to report hiatal cruralplasty with primary bariatric surgery. The 2013 code pair edit excludes the reporting of CPT 43280 with primary bariatric surgery codes, without exception, for Medicare beneficiaries. The 2013 edit does not prevent the surgeon from performing the work when indicated. The reasoning for the 2013 edit was that these codes were being routinely reported together for a large percentage of patients and the majority of use was to report a simple anterior figure of eight suture. This additional procedure did not represent a significant amount of additional work to the primary procedure.
The current code pair edit was proposed in the fall of 2014. In this case, the codes are not excluded, but must be reported with an NCCI appropriate modifier and supported with appropriate documentation. ASMBS had the opportunity to comment. Within the request for comment the NCCI specifically mentioned that paraesophageal codes (CPT 43281/2) were being over reported and used to report a “simple figure of eight suture” hiatal hernia repair.
The CPT descriptor for 43281 is below:
“The liver is retracted to allow visualization of the esophageal hiatus. The stomach is gently retracted into the abdomen to assess its degree of tethering in the thorax. The peritoneum overlying the right crus is incised, and the plane along the hernia sac is developed. The dissection is extended anteriorly and laterally to the left crus. The base of the crural confluence is dissected free of adhesions to the sac. The hernia sac is carefully dissected into the mediastinum with caudal traction. The interfaces between the pleura, pericardium, spine, and aorta are developed as the dissection is carried cephalad to the top of the hernia sac. The sac contents are completely reduced back into the abdominal cavity. The hernia sac is then excised taking care to avoid injury to stomach and vagal trunks. An esophageal dilator may be placed transorally. The esophagus is identified and dissected circumferentially and along its mediastinal course in order to reduce tension, allowing the gastroesophageal junction to rest comfortably within the abdominal cavity. Care is taken to identify and preserve the vagus nerves. The gastro-splenic ligament and the short gastric vessels are divided if necessary. The retro-esophageal window is developed, and the esophagus is retracted caudally. The crural pillars are then approximated with sutures. Anterior reinforcement of the diaphragm is performed with sutures as needed, the tightness of the repair being gauged visually or by the presence of the bougie or other device. Partial or total fundoplasty is then performed with sutures. (Additional sutures may be placed to attach the gastric fundus and/or body to the diaphragm.)”
CPT 43282 – the above repair with the implantation of mesh reinforcement.
Using CPT 43281/2 for a simple anterior figure of eight suture without the appropriate dissection represents a misreporting of the paraesophageal repair code (CPT 43281/2). Based on the 2013 code pair edit, the NCCI feels that this minimal procedure is “incidental” to the primary bariatric procedure.
When the identified hiatal hernia requires the dissection quoted above, the 2015 code pair edit allows reporting CPT 43281/2 with a NCCI appropriate modifier. Per the NCCI manual, “modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use. If the Medicare program imposes restrictions on the use of a modifier, the modifier may only be used to bypass an NCCI PTP edit if the Medicare restrictions are fulfilled. Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI PTP
Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI Global surgery modifiers: 24, 25, 57, 58, 78, 79 Other modifiers: 27, 59, 91, XE, XS, XP, XU”
Based on the ASMBS communications with the NCCI, the NCCI recommended modifier for use in the case is Modifier 59.
Per the CPT Manual:
Modifier 59 - Distinct Procedural Service:
“Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59
In Summary, if a full paraesophageal hernia repair that includes complete dissection of the hiatus, dissection of the esophagus, resection of the hernia sac, posterior closure of the crural pillars, fundoplasty and/or gastro/esophagopexy is performed, the procedure can be reported (and paid ) when the repair is performed in conjunction primary bariatric surgery. The paraesophageal hernia repair should be reported using CPT 43281/2 with a 59 modifier. However, the paraesophageal hernia repair requires documentation indicating the need for a “different procedure or surgery, or a different site or organ system” and appropriate documentation of the repair performed.
Based on past use of NCCI edits by private insurers, surgeons should expect some denials of claims filed with private insurers. The Society feels there is strong basis for appeal based on the current NCCI edits specifically allowing a 59 modifier. Success of these appeals will largely hinge on the precise documentation of the anatomy of the hernia and the conduct of the repair as well as preoperative demonstration of hernia via UGI and/or EGD. Familiarization with the CPT patient vignette and the above CPT descriptor is advised.