General Surgery Coding Alert

Hernia location is key to coding claims correctly.

Hernia repairs are commonly performed in any general surgery practice or department, but coding these surgeries can be challenging. So, to make things simpler, we’ve put together three hernia repair-specific scenarios to help you secure reimbursement for these commonplace procedures.

Read on to sharpen your hernia coding skills.

Scenario #1: An adult patient presented for left inguinal hernia repair. The patient was taken to the operating room where a left groin incision was made. Dissection was carried down through Scarpa’s fascia to the external oblique fascia, which was opened. The spermatic cord and its contents were mobilized up to the internal ring, revealing a direct defect. No indirect hernia sac was found. A moderate sized cord lipoma was dissected away from the cord structures, ligated and excised. The inguinal floor was opened; the preperitoneal space bluntly developed. Mesh was secured to the pubic tubercle and tacked to the rectus. A slit was made in the mesh and the two cut edges encircled around the spermatic cord creating a new internal ring. The spermatic cord was then returned to its anatomic position. The wound was closed in layers; Steri-strips and a sterile dressing were placed. The patient was extubated and in stable condition.

Can CPT^® code 55520 (Excision of lesion of spermatic cord (separate procedure) -59 (Distinct procedural service) be reported for the excision of the spermatic cord lipoma via the same incision as the hernia repair since the hernia repair and lipoma excision are from two different body systems?

Answer: In this case, you should assign CPT^® code 55520, with modifier 59 appended for the excision of the lipoma. Although 55520 is designated as a separate procedure, the medical record documentation supported the cord lipoma removal, and this was distinct and not inherent to the hernia repair. The lipoma was removed from the urinary tract and the hernia repair was in the abdomen; therefore, the lipoma excision may be reported separately. This is consistent with CPT^®’s “Separate Procedure” guideline and the National Correct Coding Initiative (NCCI) policy manual that advises modifier 59 may be appended to indicate a procedure or service was distinct and independent, including representing a different lesion or organ system.

Report also the primary service of the hernia repair. According to Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager, MRO, in Philadelphia, “Surgeons often do not include in their documentation enough detail for us to select a diagnosis code, so query the surgeon regarding incarceration and gangrene, and whether it is definitive to choose an appropriate code.”

Scenario #2: A 55-year-old patient presents four months after having gastric bypass surgery complaining of a painful red lump at the incision site. Coughing or sneezing makes the protrusion more pronounced. The patient is experiencing nausea and vomiting. Following a computed tomography (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 6 cm defect using mesh to prohibit hernia recurrence.

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

• An incisional hernia, or ventral hernia, occurs when tissue protrudes through an abdominal scar.
• A reducible hernia can be pushed back through the 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. An irreducible hernia may be strangulated, meaning 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).

Answer: You would code this case using 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).

Don’t forget: The diagnosis should be coded as K43.0 (Incisional hernia with obstruction, without gangrene). According to Joy, “You should also code K95.89 [Other complications of other bariatric procedure]. Remember that ICD-10 has many codes to describe when a condition is a complication or adverse effect of another situation.”

Scenario #3: The surgeon performed a laparoscopic gallbladder removal for a 35-year-old patient. During the same session, the surgeon performed an open repair of an incarcerated 2.4 cm spigelian hernia. Should you report two procedure codes for this?

Answer: The typical incision sites for a laparoscopic cholecystectomy would be distinct from the semilunar line repair of a spigelian hernia. Assuming there is documentation of different incisions for the laparoscopic procedure and the open hernia repair, you should code both procedures.

The appropriate codes would be 47562 (Laparoscopy, surgical; cholecystectomy) and 49592 (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, incarcerated or strangulated).

Caution: The NCCI bundles 49592 as a Column 2 code to 47562. However, you may override the edit pair for different anatomic sites or incisions. Assuming the separate incisions or sites are in evidence in the op report, you could append modifier 59 to 49592 to help with reimbursement.

Take note: Because CPT^® 2023 changed the hernia codes in a manner that lumps together epigastric, incisional, ventral, umbilical, and spigelian hernias, you need to carefully assess the surgical sites to determine if procedures are bundled. For instance, an umbilical hernia repair is more likely to be bundled with a laparoscopic cholecystectomy because most of those procedures use an umbilical incision for the procedure.

“Codes [49591-49596, and 49613-49618] are reported only once, based on the total defect size, for however many abdominal hernias the patient has that are getting repaired in that surgical session,” said Kelly Shew, RHIA, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, documentation and coding education specialist at Olympia Medical in Livonia, Michigan, in the 2023 AAPC Ask & Learn Webinar titled, “2023 Changes for Hernia Coding.”

This is an important point because even if the provider is repairing multiple hernias in the abdominal area, you still only report one incarcerated or strangulated repair code. This is true even with a reducible hernia. Furthermore, which code you use depends on the total measurement. “Remember to work with your surgeon on correct documentation for multiple and large hernias to meet the requirements for reporting modifier -22 [Increased procedural service]. Because most payers will reimburse an additional 20 percent, they will want to see noted additional time, effort, or complexity of at least 20 percent,” says Joy.