Summary & Overview
CPT 43335: Paraesophageal Hiatal Hernia Repair with Fundoplication
CPT code 43335 represents a surgical repair of a paraesophageal hiatal hernia performed through a chest incision that includes fundoplication and implantation of mesh or another prosthetic. This operative code captures a complex thoracic approach for hiatal hernia management and is relevant for hospitals, surgical practices, and payers because it encompasses advanced reconstructive techniques and material use that affect coding, coverage, and payment. Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will find national-level context about clinical intent and coding scope, expected service settings, and common billing considerations tied to prosthetic use and thoracic access. The publication summarizes benchmark metrics where available, highlights typical site-of-service implications (hospital OR versus ambulatory surgery center), and outlines areas where policy updates or payer-specific coverage rules commonly influence claims adjudication. Data not available in the input is noted where applicable. This piece aims to provide clinicians, hospital coding staff, and policy analysts with a concise reference for clinical and administrative aspects associated with CPT code 43335.
Billing Code Overview
CPT code 43335 describes a surgical procedure performed through a chest incision to repair a paraesophageal hiatal hernia. The operation includes a fundoplication and involves placement of mesh or another prosthetic to reinforce the repair. The description specifies this code is not appropriate for a newborn.
Service type: Inpatient or outpatient surgical repair of paraesophageal hiatal hernia with fundoplication and prosthetic implantation
Typical site of service: Hospital operating room or an ambulatory surgery center, depending on patient acuity and payer coverage.
Clinical & Coding Specifications
Clinical Context
A 62-year-old male with chronic gastroesophageal reflux disease and progressive dysphagia is evaluated after upper endoscopy and barium swallow demonstrating a large paraesophageal hiatal hernia with intrathoracic stomach and clinically significant reflux. The surgical team schedules an elective transthoracic paraesophageal hernia repair with fundoplication and prosthetic mesh reinforcement. Preoperative workflow includes history and physical, cardiopulmonary risk assessment, anesthesiology evaluation, informed consent for thoracotomy and potential conversion to open or additional procedures, and perioperative prophylactic antibiotics. Intraoperative steps include a right or left thoracotomy or thoracoscopic approach through the chest, reduction of the herniated stomach into the abdomen, cruroplasty, placement of prosthetic mesh to reinforce the hiatus, and a Nissen or partial fundoplication to restore the gastroesophageal valve. Postoperative care involves chest tube management if placed, pain control, early mobilization, swallow study as indicated prior to oral intake, diet advancement, and outpatient follow-up with surgical and gastroenterology teams for symptom assessment and monitoring for complications such as recurrence, dysphagia, or mesh-related issues.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased procedural services | Use when the work, time, or technical difficulty substantially exceeds typical for 43335 due to adhesions, prior operations, or complex anatomy. |