Wiki 2023 Hernia Repair Codes

[mfournier]

Hello Everyone:

Was wondering if I can ask how are your providers documenting the size of the hernias. Are they mentioned it within the body of the op note? As part of the procedure title?
I have one provider that it is listing it under findings:

Findings: A very small, 5 mm defect amenable to primary closure
Findings: An umbilical hernia with a 1.5 cm defect

Not sure if I should query him or give credit for the size mentioned in the findings.

Also, there is no path for these surgeries.

Thank you in advance
Miriam

 

[thomas7331]

Hello Everyone:

Was wondering if I can ask how are your providers documenting the size of the hernias. Are they mentioned it within the body of the op note? As part of the procedure title?
I have one provider that it is listing it under findings:

Findings: A very small, 5 mm defect amenable to primary closure
Findings: An umbilical hernia with a 1.5 cm defect

Not sure if I should query him or give credit for the size mentioned in the findings.

Also, there is no path for these surgeries.

Thank you in advance
Miriam

I'm not sure why you'd need to query if it's already documented under findings - I've never heard that a measurement needs to be in a particular place. It's only the steps of the procedure itself that needs to be documented in detail in the body of the note. I would be comfortable using the measurement as long as it's documented somewhere in the record of the current encounter.

In my experience, there is usually no pathology done during a hernia procedure unless the provider finds suspicious tissue during the procedure that would require it.

 

[mfournier]

Thank you for clarifying

 

[Peterk50]

Hello Everyone:

Was wondering if I can ask how are your providers documenting the size of the hernias. Are they mentioned it within the body of the op note? As part of the procedure title?
I have one provider that it is listing it under findings:

Findings: A very small, 5 mm defect amenable to primary closure
Findings: An umbilical hernia with a 1.5 cm defect

Not sure if I should query him or give credit for the size mentioned in the findings.

Also, there is no path for these surgeries.

Thank you in advance
Miriam

Mine surgeons so far are documenting in the body, "defect measurs 2 cm". I often times in some procedures fall back on pathology report if there is one.

 

[mfournier]

thank you