General Surgery Coding Alert

Question: Our surgeon performed a complex repair for a recurrent ventral hernia that involved taking down dense adhesions and removing old mesh. In the process, the op note describes three enterotomies resulting in a small bowel resection. Which services are separately billable?

Texas Subscriber

Answer: Selecting the proper code for the hernia repair requires some information you don't provide. In addition to what you do state -- recurrent ventral hernia -- you also need the following data:

• Is it reducible? The contents of a reducible hernia can be pushed back through the fascial defect. In contrast, the contents of an incarcerated or strangulated hernia are trapped in the hernia sac and cannot be pushed back through the fascial defect.
• Open or laparoscopic? CPT® provides distinct hernia-repair codes based on the approach.

Once you've answered those questions from the surgical report, you can choose one of the following codes to describe the primary procedure:

• 49565 -- Repair recurrent incisional or ventral hernia; reducible
• 49566 -- ... incarcerated or strangulated
• 49652 -- Laparoscopy, surgical, repair, ventral, umbilical, spigelian, or epigastric hernia (includes mesh insertion, when performed); reducible
• 49653 -- ... incarcerated or strangulated.

Separate resection? Whether you can separately bill the small bowel resection using a code such as 44202 (Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis) depends on documentation.

If your surgeon makes it very clear that he could not deal with the adhesions without damaging the bowel, the resection would be medically necessary and therefore billable.

On the other hand: If the surgeon simply states "in the course of taking down dense adhesions, several enterotomies were made requiring small bowel resection, which was performed without difficulty," you shouldn't separately bill the resection.