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.
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).