Question

The following documentation is from the health record of an 86-year-old female patient.

Preoperative Diagnosis:	Paraesophageal hernia
Postoperative Diagnosis:	Paraesophageal hernia
Procedure:	Laparoscopic reduction of paraesophageal hernia

256Indication The patient, a pleasant, 86-year-old female, previously presented with an acute onset of hematemesis. During this previous encounter an endoscopy was performed, which revealed a large portion of the patient’s stomach in her chest. The condition was discussed with the patient and her family. The options of open versus laparoscopic repair of her hernia were discussed. The patient and her family understood the risks versus benefits, as well as potential complications of both procedures. They supplied a copy of the patient’s DNR paperwork and elected to undergo the laparoscopic procedure.

Procedure Description: After consent was obtained, the patient was taken to the operating room and placed supine on the operating table. After adequate general endotracheal anesthesia, the patient’s abdomen was prepped and draped in the usual surgical fashion. Initial entry was gained through an infraumbilical elliptical incision. Cut down technique was used. A 5-mm trocars was inserted. A pneumoperitoneum was then obtained. Two additional 5.0 mm trocars were placed—one in the left epigastric region and another in the left upper quadrant. The initial 5.0-mm infraumbilical trocar was replaced with a 12-mm trocar. A 10-mm 30 degree scope was used throughout the procedure for visualization.

The stomach was then grasped with the soft bowel grasper and reduced from the chest in a hand-over-hand fashion. There were dense attachments of the stomach to the superior portion of the hernia sac in the chest. These were carefully taken down with the harmonics shearers. This allowed for good mobilization of the stomach and return of the stomach to the abdomen. The hernia sac was resected and sent to Pathology. The 1.0 cm defect of the diaphragm around the esophagus was repaired with mesh implantation.

The abdomen was then inspected for hemostasis which was noted to be pristine. The laparoscopic trocars were removed and the CO₂insufflation was released. The skin incisions were closed with Monocryl, benzoin, and Steri-strips and followed by sterile Band-Aids. The patient tolerated the procedure well. She was awakened, extubated, and taken to the recovery room in satisfactory condition.

What ICD-10-CM and CPT codes will be reported for the outpatient care of this Medicare patient?

1. K92.0, K44.9, 43281

2. K44.9, 49652

3. K44.9, Z66, 43282

4. K92.0, K44.9, Z66, 43659

Answer 1

ANSWER.

ICD-10-CM code.

    * K 44.9 - Diaphragmatic hernia.

    * Z66 - DNR status (Do not resuscitate).

CPT code.

    * 43282 - Laparoscopy,surgical,repair of paraesophageal hernia includes

                    fundoplasty,when performed ; with implantation of mesh.