General Surgery Coding Alert

Notice CPT^® 2023 abdominal hernia change.

When surgeons treat patients for hernia problems, you need to know a lot of details to select the correct diagnosis and procedure code.

With several ICD-10-CM hernia categories and a host of CPT^® 2023 hernia procedure revisions, we have three brief examples that will help you brush up on your coding.

Case 1: Incisional Hernia Repair

A 44-year-old female presents four months post gastric bypass surgery with a painful red lump at the incision site. Coughing and sneezing makes the protrusion more pronounced, and the patient is experiencing nausea and vomiting. Following a CT scan and blood work, the surgeon diagnoses an incisional hernia with obstruction, and performs a hernia repair, releasing the incarcerated hernia to create a patent intestinal lumen and closing the 7 cm defect using mesh to prohibit hernia recurrence.

Glossary: You need to know several terms to code this case:

• An incisional hernia, sometimes called ventral hernia, occurs when tissue protrudes through an abdominal scar.
• A reducible hernia can be pushed back through the weakened abdominal wall, while an irreducible hernia can’t.
• If the hernia is irreducible, it may be incarcerated, meaning that the trapped intestine is pinched closed, or obstructed. Even more serious, an irreducible hernia may be strangulated, meaning that the blood supply to the tissue is cut off and the tissue will die and become gangrenous.
• An abdominal hernia is a general term indicating the location of the hernia, which may be incisional, ventral, epigastric (between the sternum and the umbilicus), umbilical, or spigelian (side muscles).

CPT^® 2023 deletes many abdominal hernia repair codes for epigastric, incisional, ventral, umbilical, and spigelian hernia, bundling the procedures into replacement codes for “abdominal” repair.

Procedure: That’s why, beginning Jan. 1, you would code this case using new code 49594 (Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, incarcerated or strangulated) instead of deleted code 49561 (Repair initial incisional or ventral hernia; incarcerated or strangulated).

Diagnosis: You should code the diagnosis as K43.0 (Incisional hernia with obstruction, without gangrene).

Case 2: Hiatal Hernia Repair

A 55-year-old male patient complains of persistent acid reflux and chest pain. The patient is obese with a BMI of 40, a smoker, and has a history of gastroesophageal reflux disease (GERD). The patient’s physician sent copies of X-rays, which show a spot resembling a diaphragmatic mass.

The surgeon performs a transoral esophagoscopy for a closer look. esophagoscopy results show a paraesophageal hernia with no mention of obstruction or gangrene. The surgeon laparoscopically repairs the hernia, including fundoplasty to reinforce the sphincter muscle. Notes don’t indicate any obstruction or gangrene.

Glossary: Hiatal hernias occur when part of the stomach protrudes up through the diaphragm and into the chest cavity. The hernia may also be called a paraesophageal hernia.

Procedure: Code the surgeon’s work as 43200 (Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) and 43281 (Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh).

Notice that CPT^® 2023 does not change coding for hiatal hernia repair.

Diagnosis: Report the condition as K44.9 (Diaphragmatic hernia without obstruction or gangrene)

“The most common hernia code in our practice is K44.9. It is rare we see a hiatal hernia with obstruction or gangrene,” says Halee Garner, CPC, CPMA, CCA, certified coder for Digestive Health Partners in Asheville, NC. Obstruction or gangrene is less obvious on physical exam but is more likely to be to noted by the surgeon performing a repair. ICD-10-CM code K44.9 also covers diaphragmatic hernia not otherwise specified (NOS).

Coding alert: The K44 category has an Excludes1 note instructing you to code to Q79.0 (Congenital diaphragmatic hernia) or Q40.1 (Congenital hiatus hernia) when appropriate. These are conditions often diagnosed even before birth.

Case 3: Inguinal Hernia Repair

A 35-year-old male patient presents with persistent pain at the site of a 5 cm lump in the left groin area. The surgeon performs a full physical exam and notes that the protrusion gets bigger when the patient coughs, but may be pressed back in place. The surgeon diagnoses a reducible inguinal hernia. Due to the hernia size and associated pain, plus the patient’s occupation, which requires heavy lifting, the surgeon schedules and performs an open hernia repair procedure.

Glossary: An inguinal hernia occurs as a bulge of intestinal tissue through a weak spot in the abdominal muscles in the groin area. These hernias may be exacerbated by lifting, coughing, and straining on the toilet.

“Sometimes these [inguinal hernias] are symptomatic, sometimes not,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a former CPT^® Editorial Panel member in Pasadena, California. Acute symptoms are generally a sign of obstruction, which is more serious.

Procedure: Code the inguinal hernia surgery as 49505 (Repair initial inguinal hernia, age 5 years or older; reducible). Notice that CPT^® 2023 does not change coding for inguinal hernia repair.

Diagnosis: Report the patient’s condition as K40.90 (Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent).