General Surgery Coding Alert

Question: What is the difference between umbilical hernia and ventral hernia? What do I need to look for in the op report to decipher the correct code?

Answer: The difference is the where the hernia is located and how it formed.

As the name implies, an umbilical hernia occurs at the umbilicus (belly-button), but that's not the only criteria. An umbilical hernia involves residual structures from when the cord fed the fetus directly into the intestine. An umbilical hernia is rare, except in infants.

"Ventral hernia" is a fairly general term that may describe a hernia occurring at various abdominal sites, such as the site of a previous surgery (incisional hernia), above the umbilicus (epigastric hernia), or on the side of the abdomen (spigelian hernia). An incisional hernia might also occur at the umbilicus, but that does not make it an umbilical hernia.

An abdominal hernia occurs when the peritoneal lining of the abdominal cavity protrudes through a defect in the fascia that normally contains it. Simply stated, the fascia develops a tear, and the peritoneal lining "spills out," in much the same way that an inflated inner tube will bulge out from a cut in the sidewall of a tire. In some cases, only an empty sac protrudes through the fascia. But if the fascial defect is large enough, the sac can contain abdominal contents (typically intestines).

Here are some characteristics of each abdominal hernia type:

• Epigastric: These occur because of weakness in the muscles of the upper-middle abdomen, above the navel (the epigastric region).
• Umbilical: The fascia of the navel is thinner than in the rest of the abdomen. An umbilical hernia occurs when contents protrude from the navel.
• Spigelian: Also called a lateral ventral hernia, this is an abdominal hernia through the semilunar or spigelius line (parallel to the lateral boarder of the rectus abdominis muscle)
• Incisional/ventral: A defect in the abdominal wall at the site of a previous operative incision.

That's not all: To select the correct CPT code for hernia repair, location is only the first piece of information you'll need to glean from the op report. Additionally, you'll need to find the following information to select the proper code, in most cases:

• 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.
• Initial or recurrent? In other words, is this the first repair at this location, or does the surgeon have to "fix it again"?
• What is the patient's age? Repair codes for inguinal and umbilical hernias differentiate by patient age.
• Open or laparoscopic? Never report a laparoscopic procedure using open approach codes.