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Mastering Hernia Repair and Mesh Placement

By G. John Verhovskek, MA, CPC
To assign an appropriate hernia repair code from the more than 30 choices that CPT® offers (49491- 49590 and 49650-49659), you’ll probably need to answer at least four of the following five questions, and then read carefully through the code descriptors to find your match.
1. What is the location? For all repairs, you must know what type of hernia (such as inguinal, femoral, incisional, etc.) the surgeon treats.
2. Is it reducible? The contents of a reducible hernia can be pushed back through the fascial defect. In contrast, the contents of an incarcerated or strangulated hernia are trapped in the hernia sac and cannot be pushed back through the fascial defect.
3. Initial or recurrent? In other words, is this the first repair at this location, or does the surgeon have to “fix it again?”
4. What is the patient’s age? Repair codes for inguinal and umbilical hernias differentiate by patient age.
5. Open or laparoscopic? Never report a laparoscopic procedure using open approach codes.
Here are four tips to expedite the process:
1. CPT® lists only three codes for laparoscopic hernia repair, including two codes for inguinal hernia repair (49650, any initial repair and 49561, all recurrent repairs) and a single unlisted-procedure code, 49659, to cover laparoscopic repairs of all other hernia types, regardless of patient age or initial/recurrent, reducible/ strangulated status. If the operative report specifies a laparoscopic repair, you can narrow your choices quickly — at least, until the AMA expands the selection of laparoscopic hernia codes.
You may also want to consider S2075 and S2076 for laparoscopic repair of incisional/ventral and umbilical hernias, respectively. S codes are not accepted by Medicare, but are accepted by some Blue Cross/Blue Shield and Health Insurance Association of America payers and by some state Medicaid programs. Check with individual payers before deciding between 49659 and S2075-S2076.
2. Inguinal hernia repairs require the closest attention to detail. CPT® divides open inguinal hernia repairs into four precisely defined age groups. For the youngest patients, you’ll need to know age from time of gestation.
3. Umbilical repairs also consider age, but group patients only by “younger than age 5 years” and “older than age 5 years.”
4. Watch for “sliding” inguinal hernias. There is a separate, specific code (49525) for repair of a reducible, sliding inguinal hernia. If the hernia is strangulated, however, 49525 does not apply. Instead, you would revert to 49496, 49501, 49507 or 49521, as appropriate.

Mesh Can Be Separate

Surgeons will often place prosthetic mesh to facilitate hernia repair, but coders can only report +49568 separately when the surgeon repairs an incisional/ventral hernia (49560, 49561, 49565, 49566). For all other hernia repairs (epigastric, umbilical, etc., open or laparoscopic), you cannot claim +49568, even if the surgeon places mesh during the repair. Once again, an exception can occur if your payer will accept HCPCS temporary national codes. In that case, you could report S2077 for laparoscopic mesh placement with incisional/ventral hernia repair, in addition to S2057 (as discussed above) for the laparoscopic repair.
Occasionally, during a recurrent hernia repair, surgeons must remove implanted mesh from a previous repair. Do not report a separate code for this service. Removal of the old mesh is an included component of the recurrent repair. Don’t be fooled by +11008: Although this code describes mesh removal, it is an add-on code that applies only to debridement codes 11004-11006. You should not report +11008 with any hernia repair codes. If removal of the mesh requires significant additional time or effort, you may wish to append modifier 22 to the appropriate recurrent hernia repair code. Back up your coding with solid documentation describing in detail the extensive nature of the service, for instance by comparing it to a “typical” repair.
Finally, a surgeon might remove previously implanted mesh without a recurrent hernia repair, such as when the patient has erosion of the skin over the mesh or pain related to the implant. In these cases, you can report the mesh removal separately. Payers do not consider mesh removal a proper foreign body removal. Therefore, you must use an unlisted procedure code, such as 49999, to report the service. Be sure to include a full operative report with your claim that describes exactly what the surgeon did and why it was necessary, and you should suggest a value for the procedure.

Hernia Anatomy

An abdominal hernia occurs when the peritoneal lining of the abdominal cavity protrudes through a defect in the fascia that normally contains it. Simply stated, the fascia develops a tear, and the peritoneal lining “spills out,” in much the same way that an inflated inner tube will bulge out from a cut in the sidewall of a tire. In some cases, only an empty sac protrudes through the fascia. But, if the fascial defect is large enough, the sac can contain abdominal contents (typically intestines). Clinicians identify hernias primarily by location.
Here are a few of the most important varieties:
Inguinal: In this common form of hernia (75 percent of all hernias are of the inguinal variety), the intestine bulges through a weak area in the inguinal canal in the groin area.
Sliding inguinal: In this case, contents “slide” down the posterior abdominal wall into the inguinal canal, bringing with them overlying intestinal peritoneum. Actual bowel wall will comprise a portion of the sac.
Note: Inguinal hernias can be either “direct” (congenital) or “indirect” (acquired), but this is not a factor when coding.
Lumbar: A protrusion through the posterior abdominal wall in the area below the last rib.
Femoral: These hernias occur in the area between the abdomen and the thigh, usually appearing as a bulge on the upper thigh.
Incisional/Ventral: A defect in the abdominal wall at the site of a previous operative incision.
Epigastric: These occur because of weakness in the muscles of the upper-middle abdomen, above the navel (the epigastric region).
Umbilical: The fascia of the navel is thinner than in the rest of the abdomen. An umbilical hernia occurs when contents protrude from the navel.
Spigelian: Also called a lateral ventral hernia, this is an abdominal hernia through the semilunar or spigelius line (parallel to the lateral boarder of the rectus abdominis muscle).

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5 Responses to “Mastering Hernia Repair and Mesh Placement”

  1. Ben Jones says:

    this must old CPC coding because it doesn’t mention code 49505

  2. KEERTHANA says:

    Help me, I’m confused which CPT is appropriate for hernia repair
    CPT 49654 OR 49652?
    Operation: Robot assisted laparoscopic mesh repair of incisional ventral hernia
    Procedure: The patient was brought into the operating room. The patient was identified as correct patient. The patient was placed on operating table in supine position. Endotracheal General anesthesia was induced. Perioperative antibiotics were given. A time out was completed, verifying correct patient, procedure, site, positioning, implants and/or special equipment, blood loss, need for ICU, prior to beginning this procedure. Abdomen was prepped and draped in the usual sterile fashion.
    A small 5 mm incision made in left upper quadrant and peritoneum entered via optiview and pneumoperitoneum achieved. Underlying bowel inspected and no iniury identified. A 12mm long laparoscopic port was inserted in the middle and 8 mm robotic port inserted just above and anterior of ASIS on left side of abdomen. LUQ port was changed to 8mm robotic port. Mini lap inserted through 12 mm port and Robot was docked. A 30 up camera and scissors with cautery and Maryland grasper were used. Above findings noted. Omental and small bowel adhesions were taken down and then preperitoneal fat taken down around the hernia defects to place the mesh.. Hernia defects measured and were closed with permanent 0 Stratafix running suture.  An Atrium mosaic mesh was taken and trimmed to measurements and 2 Vicryl 0 suture were placed at the center of the mesh and in the centre of one half and mesh was rolled and inserted in the peritoneal cavity through 12 mm port. The Vicryl sutures was then brought out through the skin using carter thomason at center of hernia defects to approximate the mesh to abdominal wall. The periphery of mesh was then sutured in place with running 2-0 Stratafix. The center of the mesh was fixed in same manner using 2-0 Stratafix.  At the conclusion of case the mesh was fixed with abdominal wall without tension or folds. The Vicryl sutures was then cut flush with the skin. All needles were removed. Robot was undocked. Using laparoscopic camera, minilap were removed and peritoneal cavity was inspected for hemostasis.
    Left middle 12mm port site wound closed with Vicryl 0, figure of eight sutures using carter thomason. Port site wound closed with Monocryl 4-0 subcuticular stiches and Dermabond placed.
    All instrument, lap pad, needle count was correct x2 at the end of the procedure. The patient tolerated the procedure well and was extubated in operating room and transported to postanesthesia care unit in stable condition

  3. Suzan Louzier says:

    Hi, I am simply not sure how to code a Laparascopic recurrent inguinal hernia repair with mesh.

  4. Denise Raines says:

    Suzan, Lap recurrent inguinal hernia repair with mesh is coded 49651. Mesh is inherent and not coded separately.

  5. James Lovette says:

    “CPT® lists only three codes for laparoscopic hernia repair, including two codes for inguinal hernia repair (49650, any initial repair and 49561, all recurrent repairs)”
    The code for laparoscopic repair of recurrent inguinal hernia is 49651. 49561 is repair of initial ventral hernia.