General Surgery Coding Alert

Question: I have a question about 49505 and 49568. I am billing these codes together and some payers are paying and others are not. Medicare is paying. What I can do about the other payers who are following CPTs rules?

Texas Subscriber

Answer: This is incorrect billing, even if you are getting paid by some payers. You should immediately stop billing 49505 and +49568 together. In fact, you should also refund the carriers that paid you for these codes together.

Why? Add-on code +49568 (Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection [list separately in addition to code for the incisional or ventral hernia repair]) is for incisional and/or ventral hernia repairs only. Therefore, you should never be billing 49568 with 49505 (Repair initial inguinal hernia, age 5 years or older; reducible) because the hernia types dont match up.

Surgeons will often place prosthetic mesh to facilitate hernia repair, but you can only report +49568 separately when the surgeon repairs an incisional/ventral hernia (49560, 49561, 49565, 49566). For all other hernia repairs (epigastric, umbilical, etc., open or laparoscopic), you cannot claim +49568, even if the surgeon places mesh during the repair.

In addition: You would not use the mesh code (49568) with the new laparoscopic hernia codes (49652, Laparoscopy, surgical, repair, ventral, umbilical, spigelian, or epigastric hernia [includes mesh insertion, when performed]; reducible; 49653, &incarcerated or strangulated; 49654, Laparoscopy, surgical, repair,incisional hernia [includes mesh insertion, when performed]; reducible; 49655, &incarcerated or strangulated; 49656, Laparoscopy, surgical, repair, recurrent incisional hernia [includes mesh insertion, when performed]; reducible; and 49657, &incarcerated or strangulated) because those codes specifically state mesh is included. Reporting 49568 would be double billing for the mesh.