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Question: A 63-year-old patient who had an open incisional hernia repair with mesh five years ago presented to the emergency department (ED) with a painful, firm bulge at the superior aspect of their midline scar. Imaging with contrast revealed an abdominal wall defect. The surgeon took the patient to the operating room (OR) and performed laparoscopic repair to reduce the incarcerated small bowel without resection. The surgeon placed intraperitoneal mesh with transfascial fixation. The total fascial defect length is noted as 6 cm and the documented impression is recurrent incarcerated incisional hernia.

Should I report 49615 or 49616 for this procedure?

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Answer: You will assign 49616 (Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); 3 cm to 10 cm, incarcerated or strangulated) to report this procedure. The surgeon documented the hernia was recurrent, measured 6 cm, and was incarcerated. These factors lead you to 49616 as the correct procedure code.

Code 49615 (… 3 cm to 10 cm, reducible) also represents a recurrent hernia repair of 3 to 10 cm performed with any approach, such as laparoscopic. However, the last word in the descriptor is where the similarities stop. Code 49615 is designated for a hernia that is reducible.

Documentation tip: When coding hernia repairs, the documentation needs to include the total defect length. If this information is absent, you cannot select the correct code.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC