Q&A: Reporting procedures for gastroesophageal reflux disease in ICD-10-PCS
Q: We are seeing more fundoplication surgeries and esophageal sphincter augmentation procedures for patients with gastroesophageal reflux disease at our hospital. Do you have any tips for our coders when reporting these procedures in ICD-10-PCS?
A: For surgical intervention, fundoplication and esophageal sphincter augmentations with magnetic bands are pretty common procedures performed for gastroesophageal reflux disease, so I can see why you are seeing more of these procedures at your hospital.
First, knowing the basics of these surgeries is important for inpatient coders. During fundoplication surgery, the upper curve of the stomach (the fundus) is wrapped around the esophagus and sewn into place so that the lower portion of the esophagus passes through a small tunnel of stomach muscle.
This surgery strengthens the esophageal sphincter, which reduces the amount of acid that regurgitates into the esophagus. Since the objective of this procedure is to partially close the lumen of the esophagogastric junction, this is considered a Restriction procedure (ICD-10-PCS table 0DV) when reporting fundoplication, which may be referred to by eponyms including Nissen and Toupet.
These procedures can be performed via an open or percutaneous endoscopic approach. The open approach through the chest or abdomen is most common for those who are overweight or have an anatomically short esophagus. However, the most common approach is the laparoscopic or percutaneous endoscopic approach.
Some related ICD-10-PCS codes include, but are not limited to, the following:
- 0DV10ZZ, Restriction of upper esophagus, open approach
- 0DV14ZZ, Restriction of upper esophagus, percutaneous endoscopic approach
- 0DV20ZZ, Restriction of middle esophagus, open approach
- 0DV23ZZ, Restriction of middle esophagus, percutaneous approach
- 0DV40ZZ, Restriction of esophagogastric junction, open approach
- 0DV54ZZ, Restriction of esophagus, percutaneous endoscopic approach
More recent technology utilized for patients with gastroesophageal reflux disease includes placement of a flexible band of interlinked titanium beads with magnetic cores around the lower esophageal sphincter.
The band expands as food pushes through the esophagogastric junction, temporarily breaking the magnetic bond at the esophageal sphincter. Once the food moves through, the attraction of the magnets results in the band cinching closed again, limiting the flow of acid back up into the esophagus.
The objective of this device is also to restrict or partially close the esophagogastric junction and is also reported with ICD-10-PCS table 0DV. This device is generally placed laparoscopically around the esophagus and is considered an extraluminal device (device character C).
Editor’s note: Shannon McCall RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, HCS-D, director of HIM and coding for HCPro in Middleton, Massachusetts, answered this question.
This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
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