Hernia Repair Coding Made Easy
Differentiate hernia types and surgical approaches for improved medical coding.
A hernia occurs when tissue or an organ pushes through the wall of the cavity in which it normally resides. This abnormal protrusion occurs due to a weak spot in the surrounding muscle or connective tissue (fascia). In some cases, only an empty sac protrudes through, but if the defect is large enough, the hernia sac can contain abdominal contents, typically part of the intestine. While most hernias are not immediately life-threatening, they don’t typically go away on their own. Sometimes, they require surgery to prevent life-threatening complications.
Although there are many approaches to surgical hernia repairing, they share a common theme. Surgery is directed at permanently closing off the orifice through which the abdominal contents protrude, after returning them to the abdominal cavity. Usually, 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, it may be ligated and resected. The muscle tissue is repaired, and the incision is closed. A mesh or other prosthesis may be used for reinforcement of the muscle wall.
There are many types of hernias. This article focuses on those addressed in the abdominal repair section of CPT® (49491–49659). When you look at the hernia repair codes in this section, one thing becomes quite clear: There is quite a bit of diagnostic and demographic information you need to know to determine the correct code. The key to properly coding hernia repair procedures is knowing what questions to ask yourself as you read through the physician’s documentation.
5 Questions Guide Code Selection
To assign the appropriate hernia repair code from the more than 40 choices that CPT® offers, ask yourself the following questions and read carefully through the code descriptors to find your match.
1. Was the Surgical Approach Open or Laparoscopic?
There are two approaches to surgical hernia repair. Review the documentation to determine if the approach was open or laparoscopic.
If it’s laparoscopic, turn to codes 49650–49659 and choose which one best describes the type of hernia repaired and clinical presentation. Voilà, you’re done. If it’s open, you have a bit more work to do, so turn to code range 49491–49611 for open hernia repair.
2. What Is the Type of Hernia Being Repaired?
For all repairs, you must know the type of hernia being treated. Check the diagnostic information to identify the type such as:
- Inguinal: occurs when abdominal contents, such as fatty or intestinal tissue, bulge through a weak area in the inner groin muscle of the lower abdominal wall at the inguinal canal. This is the most common type of hernia, accounting for 75 percent of all hernias.
- Femoral: occurs when intra-abdominal tissue pushes through the wall of the femoral canal located in the upper part of the thigh near the groin, just below the inguinal ligament. It appears as a bulge near the groin or inner thigh.
- Lumbar: occurs when there is herniation through either of the lumbar triangles. This rare type of posterolateral abdominal wall defect lies between the bottom of the 12th (last) rib and the hip bone and is situated around the back of the body.
- Incisional: results from a weakening of the abdominal muscle due to a surgical incision and may occur months to years after abdominal surgery. It appears as a protrusion of fatty or intestinal tissue that forms at the site of a healing surgical scar from a previous operation.
- Umbilical: occurs when the abdominal wall layers don’t join completely and a portion of the abdominal lining, part of the intestine, and/or fluid from the abdomen protrude through the weak area in the muscle in or around the belly button, creating an abnormal bulge.
- Epigastric: occurs when a weakened area in the upper abdominal wall allows abdominal tissue to push through the muscle, resulting in a bulge located in the midline between the umbilicus and sternum (breastbone).
- Spigelian (lateral ventral hernia): occurs through a defect in the anterior abdominal wall. It protrudes through the spigelian fascia, the layer of tissue located between the semilunar line and the lateral edge of the rectus abdominis muscle.
- Omphalocele: birth defect of the abdominal wall in which the infant’s intestines, liver, or other organs stick outside of the abdomen through the belly button. The organs are covered in a thin, nearly transparent sac that is hardly ever open or broken.
3. Has the Hernia Required Previous Repair?
To report hernia repair correctly, you often need to know the episode of care. To further categorize types of hernias as “initial” or “recurrent,” ask yourself: Does the documentation indicate that this is the first repair at this location, or is the surgeon treating a hernia that’s been repaired before?
4. What Is the Clinical Presentation?
Another factor that determines correct coding is the 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.
In contrast, the contents of an incarcerated hernia are trapped in the hernia sac and cannot be pushed back (reduced) through the defect. Incarcerated hernias are more worrisome because they run a greater likelihood of becoming strangulated, which is when the blood supply to an incarcerated hernia is cut off as the vessels pass through the neck of the hernia. This is dangerous, due to the risk of gangrene when tissues die, and can be life-threatening if it isn’t treated.
5. What Is the Patient’s Age?
Repair codes for inguinal and umbilical hernias are differentiated by patient age at the time of the operation. For umbilical repairs, you must know if the patient’s age at the time of surgery was younger than 5 years or 5 years or older. For inguinal repairs, age is classified into one of the following four categories:
- Birth up to 50 weeks for a preterm infant
- 50 weeks to 6 months for a preterm infant or younger than 6 months for a full-term infant
- Between 6 months and 5 years
- 5 years and older
Mesh May Be Separate
Surgeons will often place a piece of prosthetic mesh to help strengthen the area of the abdominal wall being repaired and provide additional support to the damaged tissue. Hernia mesh is used in 90 percent of hernia surgeries and, when used and placed correctly, reduces the risk of recurrence.
The use of mesh is included in most CPT® repair codes, with the exception of incisional and ventral repairs performed via an open approach, or for closure after debridement of infected necrotic tissue. Add-on code +49568 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair) can only be reported separately with codes 49560–49566 for incisional or ventral hernia repair and debridement codes 11040–11006.
If mesh implantation is performed with any other open hernia repair (inguinal, epigastric, umbilical, femoral), do not report +49568 because those codes include mesh placement. Mesh is also included as a part of laparoscopic repair. Do not report +49568 with laparoscopic repair codes 49652–49657.
When to Report Mesh Removal
If, during a recurrent hernia repair, the surgeon removes implanted mesh from a previous operation, do not report a separate code for this service. Removal of the old mesh is included in the recurrent hernia repair. If removal of the old mesh requires significant additional time or effort, append modifier 22 Increased procedural services to the appropriate recurrent hernia repair code for proper reimbursement. Back up your coding with documentation describing in detail the extensive nature of the service and how what was done differs from a “typical” repair.
Do not use add-on code +11008 Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary procedure) to report mesh removal during hernia repair. Although it describes mesh removal, this code can only be used with 10180 Incision and drainage, complex, postoperative wound infection and debridement codes 11004–11006.
Lastly, a surgeon might remove previously implanted mesh without a recurrent hernia repair, for example, due to skin erosion over the mesh or pain related to the implant. In these cases, you can report the mesh removal separately. Note that payers do not consider mesh removal a proper foreign body removal. Since there is no separate code for implanted mesh removal, use unlisted procedure code 49999 Unlisted procedure, abdomen, peritoneum and omentum to report the service. Best practice, to avoid denials, is to include a full operative report with your claim that details exactly what the surgeon did and why it was necessary.
Understanding the specific details associated with hernia repair is imperative for proper coding and reporting. Now that you are familiar with the different types of hernias and know which details to look for in the documentation, you should be able to code abdominal hernia repairs like a pro.
8 Tips for Mastering Hernia Repair Coding
1. Sometimes the hernia can be manually reduced, although this is typically not a permanent solution. There isn’t a code for medical reduction of a hernia; it is considered part of an evaluation and management (E/M) service. Simply assign the appropriate E/M code.
2. Placement of mesh (+49568) is an add-on code used only for incisional or ventral hernia repairs performed via an open approach (49560–49566) or for mesh closure following debridement of necrotic tissue (11004–11006).
3. Do not bill for mesh implantation (+49568) if laparoscopic hernia repair was performed, as it is included in the repair codes.
4. Codes 49491–49651 describe unilateral hernia repair procedures; if performed bilaterally (same approach, same condition), append modifier 50 Bilateral procedure to the appropriate code to report bilateral hernia repair (e.g., bilateral recurrent inguinal hernias). If hernia repair is unilateral, use modifier RT Right side or LT Left side to indicate the side.
5. Inguinal hernia repair coding requires close attention to detail. CPT® divides open initial inguinal hernia repairs into four precisely defined age groups. For the youngest patients, you’ll need to know gestational age at birth.
6. Umbilical repairs also account for age but classify patients into only two groups: “younger than age 5 years” and “older than age 5 years.”
7. Watch for sliding inguinal hernias. This is a rare type of inguinal hernia in which a retroperitoneal organ “slides” down the posterior abdominal wall and herniates into the inguinal canal, dragging overlying peritoneum with it. There is a separate, specific code — 49525 Repair inguinal hernia, sliding, any age — for the repair of a reducible, sliding inguinal hernia. If the hernia is incarcerated or strangulated, however, 49525 does not apply. Instead, you would revert to 49496, 49501, 49507, or 49521, as appropriate.
8. CPT® code 49659 Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy is reported when a CPT® code does not exist for the type of repair performed.