ICD-10 Coding for Nissen Fundoplication(0DSU4ZZ)
Complete ICD-10-CM coding and documentation guide for Nissen Fundoplication. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Nissen Fundoplication
0DSU4ZZ-0DSU8KZPrimary Range
ICD-10-PCS codes for Nissen Fundoplication procedures
These codes cover the surgical procedures for Nissen Fundoplication, including laparoscopic and open approaches.
Key Information: ICD-10 code for Nissen Fundoplication
Essential facts and insights about Nissen Fundoplication
Primary ICD-10-CM Code for nissen fundoplication
Decision Criteria
clinical Criteria
- Laparoscopic approach confirmed
Applicable To
- Laparoscopic anti-reflux surgery
Excludes
- Open Nissen Fundoplication
Clinical Validation Requirements
- 360° gastric fundus wrap measuring [X] cm length
- Crural repair with [suture/mesh] reinforcement
Code-Specific Risks
- Ensure documentation includes wrap length and crural repair details.
Coding Notes
- Ensure the procedure is documented as laparoscopic and includes all necessary details for validation.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Biologic mesh placement
0JSW0JZDifferential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Open Nissen Fundoplication
0DSU07ZDocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Nissen Fundoplication to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code 0DSU4ZZ.
Impact
Clinical: Inadequate procedure validation., Regulatory: Non-compliance with documentation standards., Financial: Potential reimbursement issues.
Mitigation Strategy
Include wrap length in operative notes.
Impact
Reimbursement: Denials due to unbundling., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate procedure reporting.
Mitigation Strategy
Bundle the hernia repair with the fundoplication code.
Impact
Risk of unbundling procedures that should be coded together.
Mitigation Strategy
Review coding guidelines for bundled procedures.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Nissen Fundoplication, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Nissen Fundoplication
Use these documentation templates to ensure complete and accurate documentation for Nissen Fundoplication. These templates include all required elements for proper coding and billing.
Laparoscopic Nissen Fundoplication
Specialty: GastroenterologyRequired Elements
- Procedure details
- Wrap construction
- Crural repair
- Mesh documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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