Mesh Implantation
Nevada Subscriber
Answer: Mesh is always used during any laparoscopic repair. Therefore, do not bill 49568 (implantation of mesh or other prosthesis for incisional or ventral hernia repair [list separately in addition to code for the incisional or ventral hernia repair]) even if it occurs during the same operative session as a laparoscopic ventral hernia repair.
Mesh implantation is payable separately when performed with open ventral and incisional hernia repairs, but is included in open repair of umbilical and other hernias. Although the umbilical hernia can be considered a type of ventral hernia, this is not relevant in terms of coding open umbilical hernia repairs because the codes that should be used -- 49580, repair umbilical hernia, under age 5 years; reducible; 49582, ... incarcerated or strangulated; 49585, repair umbilical hernia, age 5 years or older; reducible; and 49587, ... incarcerated or strangulated -- are by definition more specific than are similar ventral hernia codes, i.e., 49560, 49561, 49565 and 49566.
Note: Repair of a recurrent umbilical hernia is considered an incisional hernia. As a result, mesh implantation, when performed, may be billed separately.
Often, the physician may believe the hernia is umbilical, only to discover a ventral hernia (defined as any hernia on the abdominal wall other than inguinal, femoral and -- when the hernia truly is in the navel -- umbilical hernias) instead. For example, women who have had hysterectomies may have a herniated lower abdominal scar that may appear umbilical on physical examination but proves to be incisional when explored surgically. In such cases, it may be difficult for the surgeon to assess with certainty the nature of the hernia prior to surgical exploration.
Many carriers require a CPT code before precertifying or preauthorizing a procedure or treatment. If, as is often the case, the surgeon suspects an umbilical hernia but is uncertain until surgical exploration, obtain pre-authorization for the ventral hernia (if the documentation includes a note that indicates that the surgeon suspects the ventral hernia may in fact be umbilical) because an umbilical hernia has not yet been confirmed. Obtain pre-authorization for mesh implantation at the same time.
If preauthorization is obtained for an umbilical hernia repair, the carrier is unlikely to authorize mesh implantation also because this is included in the umbilical repair code. If, in the end, the hernia was not umbilical and the operative notes state incisional hernia repair with insertion of mesh, the preauthorized code will not match the procedure being billed -- which may result in a complete denial of the claim.
If preauthorization has been obtained for a ventral hernia that is found to be umbilical, the codes also will not match. This is easier to adjudicate, however, because the relative value units for umbilical repair are less than those for ventral/incisional hernia repair.
Note: When the type of procedure to be performed changes, the physician should inform his staff within 24 hours so they can inform the carrier, or the claim may be denied. When the visit and procedure are billed, the diagnosis codes for ventral hernia (552.x, ventral hernia with obstruction, or 553.2x, ventral hernia without obstruction) should usually be linked to the visit that determined the need for the hernia repair, whereas the umbilical diagnosis (553.1, umbilical hernia) should be associated with the hernia repair.
Correct coding depends on the surgeons documentation. If the procedure notes state that an open umbilical hernia repair was performed, it should not be billed as an open ventral hernia and, therefore, implantation of mesh cannot be separately billed.
If the umbilical hernia is repaired laparoscopically, use 49659 (unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy), as there is no specific CPT code for this procedure.
