General Surgery Coding Alert

You may need to appeal to make your case and get proper payment.

When your general surgeon performs more than one hernia repair during the same session, even in different anatomical areas, figuring out the proper coding can stump even the best coders. Test your know-how with this real-life case study.

Review the Surgical Case

Scenario: A general surgeon performed an initial laparoscopic incisional hernia repair with mesh insertion for a reducible hernia. During the same laparoscopic procedure, the surgeon also performed an initial inguinal hernia repair for a strangulated hernia.

Coding dilemma: "Our general surgeons perform multiple hernia repairs. We are not getting reimbursement back for the second repair in many cases. I know that many insurance companies will not reimburse back when it is done through the same incision, but many of ours are done through separate incisions. What is the best way to code these to get reimbursement?" asks Stacey Sands, CCA, with Advanced Surgical Associates in Lees Summit, Mo.Unlock payment for multiple hernia repairs in one session with these four tips.

1. Different Hernias Should Mean Separate Payment

Myth: For this scenario, you may think you cannot report both hernia repair procedures.

Reality: You can code for both procedures if the patient has two different hernias, such as an incisional and an inguinal hernia as in this case, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program. You'll earn that separate payment using modifier 59 (Distinct procedural service) to indicate that the surgeon performed two distinct procedures during the same session.

"These hernias involve completely different areas and should not be grouped together even if they can be approached from the same incision (e.g., laparoscopic approach)," Bucknam warns. "Be sure you also include the two different diagnoses." In this scenario your coding should be:

• 49654 (Laparoscopy, surgical, repair, incisional hernia [includes mesh insertion,when performed]; reducible) with a diagnosis of 553.21 (Ventral hernia, incisional)
• 49650-59 (Laparoscopy, surgical; repair initial inguinal hernia) with a diagnosis of 550.90 (Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified [not specified as recurrent]).

2. Appeal if Payer Denies Second Code

When you have two separately reportable hernia repairs, you may need to appeal on a denial of one part of the claim. With an appeal and the proper documentation, you should see payment.

Tip: When you bill a complicated procedure and receive a denial that you know is unwarranted, a standard appeal may not be your best bet. You can request that the payer have a physician from your specialty review the claim and documentation.

Don't let just a payer employee or a general physician (who can be of any specialty) review your surgical claim. Request that a qualified specialist -- a general surgeon -- review the appeal, because he would best understand the procedure your physician performed, the documentation, and the coding.

"You should ask for a specialist to review any appeal, not just those denied for medical necessity," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Good practice: Add a statement requesting a specialist review to every appeal letter you submit, Cobuzzi says. She suggests using wording such as: "Since the only physician who would be qualified to review these notes would be a surgical specialist, we are requesting that these notes go to that specialist before a decision is made."

3. Two of the Same? Stick With 1 Code

When your surgeon performs two hernia repairs during the same session, but the hernia are the same type your coding options -- and reimbursement -- will change.

"If the patient has two ventral or incisional hernias it is my thought that this will really never be separately payable," Bucknam says. "And this also applies to umbilcal hernias and incisional hernias, especially if they are repaired laparoscopically."

Here's why: Payers think that since your surgeon needs to repair the abdominal wall as part of the closure anyway, there is not a lot of additional work for the physician to repair. Therefore, they aren't willing to separately pay for the second hernia repair.

Consider a modifier: If your surgeon documents that there was actually a significant amount of extra work involved in performing both procedures, you may want to try appending modifier 22 (Increased procedural services). "Your surgeon will need to describe that the patient actually had more than one defect and should include how much additional time was involved in repairing the second hernia (compared to just repairing one)," Bucknam explains.

"If the additional work (time) is at least 50 percent more than usual, it is possible to receive additional reimbursement of 25 percent of the main code billed."

4. Bill the Patient For Extra Costs

If you expect that your surgeon will be performing two hernia repair procedures during one session and you don't expect the patient's insurance company to pay for both, you can have the patient sign a form indicating he knows he will have to pay for the additional cost.

Beware: If the patient has Medicare coverage you cannot bill the patient even if you have him sign an advance beneficiary notice (ABN). "Getting a promise to pay (whether you use Medicare's ABN form or develop another one) will only help for payers that you do not have a contractual requirement to write off disallowed charges," Bucknam says. "In other words, it won't help with Medicare or Medicaid or with most of the Blues or United Healthcare or most other major payers that require a contractual relationship for payment. It will only help with independent insurers or self-insured companies or other smaller reimbursement sources. The key here is to check your contracts."

Remember: When you bill the patient, you should not charge the full fee for the second hernia repair since some of the work will be included in the coding for the first procedure. Just as payers apply multiple procedure discounts for more than one procedure in the same session, you should do the same when billing the patient.

"Certain aspects of both repairs do not have to be repeated for each hernia including all of the preoperative work, the incision, closure, and post-op visits and other aspects like in-hospital visits, bandages, writing the op note etc.," Bucknam says.