General Surgery Coding Alert

Question: I read your You Be the Coder about a hernia repair and bowel repair in the Vol. 12, No. 8 issue. Is the reason for not billing both the right inguinal incarcerated hernia and ischemic  bowel because the documentation doesn't state the bowel was strangulated/ incarcerated in the hernia? Per CPT guidelines "the excision/ repair of strangulated organs or structures such as testicle(s), intestine, ovaries are reported by using the appropriate code for the excision/repair (e.g., 44120, 54520, and 58940) in addition to the appropriate code for the repair of the strangulated hernia." Florida Subscriber

Answer: Although CPT allows separate billing for excision or repair of organs damaged due to incarceration, most payers will not pay for this separately. The logic is that the provider would have had to repair the abdominal wall as part of the excision or repair and therefore this doesn't represent enough separate work to allow separate payment.

In writing: Medicare states this in their National Correct Coding Initiative (NCCI) Policy Manual: "If a hernia repair is performed at the site of an incision for an open abdominal procedure, the hernia repair (CPT codes 49560-49566) is not separately reportable. The hernia repair is separately reportable if it is performed at a site other than the incision and is medically reasonable and necessary. An incidental hernia repair is not medically reasonable and necessary and should not be reported separately." (NCCI Policy Manual for Medicare Services, Version 15.3 - Effective October 1, 2009, www.cms.gov/NationalCorrectCodInitEd)

Although you may find the occasional payer who will separately reimburse for hernia repairs, it is very rare. Check with your individual payer to see if it will reimburse you separately, and under what circumstances.