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Hint: The reason for the mesh removal determines the code.

Hernia repairs are a frequent occurrence in any general surgery practice or department, yet their coding can present difficulties, especially with the updates to so many CPT^® hernia repair codes that appeared in 2023. To keep you on top of your game, we’ve put together some of the most frequently asked questions (FAQs) related to hernia repair procedures.

Keep reading to see how your hernia coding knowledge measures up.

Understand That Size Matters in Hernia Repair

Question 1: How do you determine the size of the hernia repair when the documentation is unclear?

Answer: The total size of the hernia repair is required to report it accurately. Because fascia can retract once a patient is opened, this measurement needs to be taken beforehand.

If you are unsure of the actual size of the hernia and are using an approximation, you should use the smaller of the measurements from the practitioner’s notes. For example, in instances where the provider’s documentation is unclear, stating the hernia to be around 3 cm — a measurement that borders between two codes — it’s smart to choose the code corresponding to a hernia less than 3 cm, such as 49591 (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); less than 3 cm, reducible), to avoid a claim denial.

Note: This situation presents an ideal chance to engage in an informative discussion with your surgeons. Providers invariably aim for fair compensation, which can only be achieved through precise measurements before hernia surgery begins. Helping them to understand the importance of accurate and conservative measurement choices can save you time and the need to query them in the future.

Find Out if Global Periods Are a Thing of the Past

Question 2: If a patient has hernia repair surgery and returns 10 days later for suture removal, is that included in their initial surgery’s global days?

Answer: The hernia repair codes saw some major changes in 2023. One of those major changes was that they now have zero global days. This means that any follow-up appointments or services that the patient needs will now be billed separately.

For example, if a patient stays one night after surgery and is discharged the following day, you can report 99238 (Hospital inpatient or observation discharge day management; 30 minutes or less on the date of the encounter) or 99239 (… more than 30 minutes…) for the day following the procedure. If the provider cared for the patient for five hospital days, they could now report an inpatient evaluation and management (E/M) code for each day the patient was seen.

A zero-day global period also means that you can separately report any simple follow-up services, such as wound debridement or suture removal that are done in the office. Overall, this makes coding considerably easier. You no longer need to monitor any follow-up services, which simplifies the tracking and compensation procedures in contrast to procedures with extended global periods.

Use Caution When Using Unlisted Codes

Question 3: If a femoral hernia containing fatty tissue is identified and reduced during an exploratory laparoscopic procedure for a complaint of a bulge in the patient’s thigh, should this be billed as a hernia repair using 49550, or is adding modifier 22 more appropriate because of the exploratory laparotomy?

Answer: Using 49550 (Repair initial femoral hernia, any age; reducible), would not be appropriate in this instance because that code describes an open hernia repair procedure.

CPT^® does not include a code for laparoscopic femoral hernia repair, so your only choice would be 49659 (Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy).

Appending modifier 22 (Increased procedural services) to 49550 would not be appropriate in this case because the service you describe is not an open procedure that takes additional work. Instead, it is a completely different procedure.

You also should not use modifier 22 with 49659, because unlisted codes don’t match any fixed, described procedure. Using modifier 22 in that case would suggest that you did something extraneous beyond a specific, defined procedure.

Make note: When using an unlisted procedure code, be sure you provide clear and detailed documentation describing the procedure performed. Your practitioner will need to include a comprehensive summary of the intervention, the rationale for its use, any equipment or materials involved, and any complications or specific circumstances surrounding the case.

Remember that unlisted procedure codes are only to be used when no other existing codes accurately reflect the specific service or treatment being provided. The use of unlisted codes may require additional approval from insurance companies or other payers, and there could be challenges in obtaining reimbursement for these services.

Learn if Mesh Removal Reason Makes a Difference

Question 4: Do anterior abdominal hernia repair codes 49591-49618 (Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic) …) include removal of mesh as well as the implantation if necessary?

Answer: No, these codes don’t include mesh removal.

For the removal of mesh, you will turn to add-on code +49623 (Removal of total or near total non-infected mesh or other prosthesis at the time of initial or recurrent anterior abdominal hernia repair or parastomal hernia repair, any approach (ie, open, laparoscopic, robotic) (List separately in addition to code for primary procedure)), to be used in conjunction with codes 49591-49622.

Be aware: The code descriptor for +49623 specifies it is for the removal of non-infected mesh only. If the surgeon documents removing infected mesh, you would use +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)).

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC