Code Fat Albert’s HERNIA REPAIR in 5 Easy Steps

Push your hernia coding to where it belongs, with the experts.

By Melissa Brown, RHIA, CPC, CPC-I, CFPC

Comedian Bill Cosby tells an entertaining story about being the center of attention after he gave himself a hernia lifting a heavy sewer lid. The punch line involves what happens when Fat Albert—the cartoon character voiced by Cosby—gets a hernia of his own. As I listened to the story with my kids recently, my coder brain kicked into gear. What kind of hernia did he have? How would you code the repair? In the process of satisfying my curiosity, I found some great information to share about hernias.

A hernia occurs wherever an internal body part pushes beyond a confining wall into an area where it doesn’t belong. There are many types of possible hernias; however, let’s focus on the hernia types addressed in CPT® codes 49491-49659. These codes are classified by hernia type, with additional classifications for episode, clinical presentation, and patient age.

Although there are many approaches to surgically repairing a hernia, they share a common theme. Generally, an incision is made over the hernia, and the hernia sac is dissected from any surrounding structures. The contents are examined for viability and returned to their original site, if appropriate. Depending on the size of the hernia sac, the sac may be ligated and resected. The muscle tissue is repaired and the incision is closed. A mesh or other prosthetic may be used for reinforcement of the muscle wall.


Illustrations © Ingenix OptumInsight

1. Identify the Type of Hernia

To select an appropriate repair code, first identify the types of hernias described in 49491-49659.

Inguinal Hernia (49491-49525, 49650-49651): An inguinal hernia is a very common hernia that occurs when abdominal contents (such as the intestines) protrude through the inguinal canal due to a weak point in the lower abdominal wall. These are commonly referred to as groin hernias because they appear just above the leg crease, close to the pubic area. CPT® code selection does not differentiate between direct (superficial inguinal ring) and indirect (deep inguinal ring) inguinal hernias.

Lumbar Hernia (49540 Repair lumbar hernia): Not to be confused with the lumbar disk hernia, lumbar hernias are rare hernias occurring through defects in the parietal abdominal wall in any area of the lumbar region (between the last rib and the iliac crest where the transverse muscle is covered by the latissimus dorsi).

Femoral Hernia (49550-49557): Femoral hernias are visible in the upper part of the thigh near the groin. They are often hard to distinguish from inguinal hernias on examination alone, although they typically occur lower in the groin (near the inner thigh).

Incisional (49560-49568, 49654-49657): When the hernia occurs at the site of a previous abdominal surgery (incision), it is called an incisional hernia. The incision for surgery creates an area of weakness, making it prone for herniation. These hernias may appear weeks, months, or even years after the surgery.

Ventral (49560-49568): Ventral means front (from Latin, meaning belly), so a ventral hernia is one that occurs anywhere on the abdomen. Ventral hernias commonly occur along the midline of the abdominal wall.

Epigastric (49570-49572): These are similar to the umbilical hernia, but are situated higher between the breastbone and the belly button (picture the six pack abdominal muscles area). Epigastric hernias are typically made up of fat rather than internal organs. Epigastric hernias are not synonymous with hiatal hernias. Hiatal hernias occur when part of the stomach protrudes up into the chest through a weakness in the diaphragm at the hiatus.

Umbilical (49580-49587): Umbilical hernias are most often seen in infants, at or near the bellybutton. This area has a natural weakness from the blood vessels of the umbilical cord, presenting a prime location for a hernia. It is possible for the area of weakness to persist through adulthood; these types of hernias are not limited to pediatric patients.

Spigelian (49590 Repair spigelian hernia): The spigelian hernia is sometimes referred to as a lateral ventral hernia. These hernias occur laterally along the outer edge of the six-pack abdominal muscles in the spigelian fascia. These hernias occur between the muscles of the abdominal wall and are difficult to detect due to little outward evidence of swelling.

Omphalocele (49600-49611): This birth defect occurs when the infant’s abdominal wall does not develop properly. The intestine or other abdominal organs remain outside the abdomen, through the umbilicus, and is covered only by a thin layer of tissue.

2. Define the Episode of Care

To report hernia repair appropriately, you must often know the episode of care. An initial hernia is one that has not been previously repaired. A recurrent hernia is one that appears at the site of a previous hernia repair. This can happen if the incision site weakens, or if there is infection or improper healing of the wound. The conditions that caused the original hernia (for example, obesity or nutritional disorders) may persist and encourage the development of a recurrent hernia.

3. Verify the Clinical Presentation

Another factor that determines correct coding is clinical presentation of the hernia. When the contents of the hernia sac return to their normal location spontaneously or by gentle manipulation, the hernia is considered reducible. While moving the contents may make the hernia appear smaller or disappear, the weakened tissue still needs to be repaired to avoid recurrence of the hernia.

When the herniated tissue becomes trapped and cannot be pushed back (reduced), the result is an incarcerated hernia, also called a strangulated hernia. Incarcerated hernias are more worrisome because they run greater likelihood of becoming strangulated, which happens when the blood supply to an incarcerated hernia is cut off. These types of hernias are dangerous due to the risk of gangrene when tissues die.

4. Determine Patient Age

According to instruction in the CPT® manual, when the patient’s age is necessary for code selection of hernia repairs, use the patient’s age at the time of the surgery. CPT® notes also help with the calculation of post-conception age, as needed, for codes 49491-49496. The notes instruct us to use gestational age at birth plus age in weeks at the time of the hernia repair.

5. Put It All Together

Now that you know what to look for, apply the steps to an actual note:

PROCEDURE IN DETAIL: The 12-year-old (step 4: identify patient age) male patient was prepped and draped in the sterile fashion. An infraumbilical incision was formed and taken down to the fascia. The umbilical hernia (step 1: identify type) carefully reduced (step 3: clinical presentation) back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia, and then the wounds were infiltrated with 0.25% Marcaine. The skin was reattached to the fascia with 2-0 Vicryl. The skin was approximated with 2-0 Vicryl subcutaneous, and then 4-0 Monocryl subcuticular stitches, and dressed with Steri-Strips and 4 x 4’s. Patient was extubated and taken to the recovery area in stable condition.

Note, for Step 2: Define the Episode of Care, there is no reference to a prior repair, so this would be treated as an initial hernia.

Armed with this information, we can look at codes 49580-49587. Because the patient is over 5-years-old, we narrow the selection to 49585-49587. And, because we know the hernia was reducible, we can select 49586 Repair umbilical hernia, age 5 years or older; reducible.

Melissa Brown, RHIA, CPC, CPC-I, CFPC, is manager of reimbursement and quality improvement, University of Florida Jacksonville Physicians, Inc. She has 19 years of experience in the health care industry. Ms. Brown’s areas of expertise also include fee analysis, budgeting and Physician Quality Reporting System (PQRS). Toastmasters International awarded her its highest honor, Distinguished Toastmaster (DTM). She served as co-director of the annual “Coding on the River” convention in Jacksonville, Fla. for several years.


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