General Surgery Coding Alert

Question: A patient had a right inguinal incarcerated hernia. When the doctor dissected the hernia sac, he noticed some ischemic bowel. The doctor documents in the op report "careful dissection of this down to a knuckle of bowel, which was ischemic." Is this incidental to the hernia repair or can I code for the partial small-bowel resection? If not, can I add modifier 22 to the hernia repair for the extra work involved?

Missouri Subscriber

Answer: You should actually code the bowel resection instead of the hernia repair in this case. Therefore, you would report a code such as 44120 (Enterectomy, resection of small intestine; single resection and anastomosis) for an open approach or 44202 (Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis) for a laparoscopic approach. Your primary diagnosis code will most likely be ischemic bowel disease (557.x).

Skip the hernia repair code and leave codes such as 49507 (Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated) or 49650 (Laparoscopy, surgical; repair initial inguinal hernia) off your claim.

Here's why: Your payer will bundle the two codes, paying you just for one. Since the bowel resection is the higher-valued code " and that procedure is more invasive and complicated -- you should report just the bowel resection and consider the hernia repair incidental.

Modifier possibility: If your surgeon documented a lot of extra work in the hernia repair, you can add modifier 22 (Increased procedural services) to the bowel resection code to capture extra pay for the extra time and effort.

Remember, however, that payers won't accept a modifier 22 claim unless you can provide convincing evidence that the service or procedure was truly "out of the ordinary" and significantly more difficult or time-consuming than usual.