General Surgery Coding Alert

Question: During an open hernia repair for a reducible umbilical hernia, the surgeon finds a sizeable gallstone embedded in the omentum extending into the preperitoneal fat. The surgeon excises the gallstone granuloma with cautery. Patient history indicates cholecystectomy eight years ago. What are the correct ICD-9 and CPT codes?

Utah Subscriber

Answer: The proper procedure code for this scenario is 49585 (Repair umbilical hernia, age 5 years or older; reducible). If the gallstone resection represents a significant amount of extra time and effort, modifier 22 (Increased procedural services) would be appropriate.

Watch out: You should not report the omentum gallstone resection (49255, Omentectomy, epiploectomy, resection of omentum [separate procedure]) in addition to the 49585 hernia repair. As a designated "separate procedure" code, you should only list 49255 if it is the only procedure the surgeon performs at the site. Because you indicate that the gallstone is imbedded in the omentum and extends only partially into the peritoneum, you should not code the service as a peritoneal foreign body removal (49402, Removal of peritoneal foreign body from peritoneal cavity).

As to ICD-9 codes, the documentation can make a big difference. If your surgeon indicates that he thinks the gallstone was dropped and left in the omentum during the previous surgery, you should consider it a foreign body left during surgery and code 998.4 (Foreign body accidentally left during a procedure). Otherwise, the best diagnosis choice is 568.9 (Unspecified disorder of peritoneum). Report the umbilical hernia as 553.1 (Umbilical hernia).