Escondido, CA
Best answers
It's my understanding that 49320 can only be billed if the findings lead to an open procedure?

Strangulated umbilical hernia with small bowel obstruction.

Laparoscopic exploration and laparoscopic reduction of incarcerated
intestine as well as open umbilical hernia repair primarily.

A loop of intestine stuck within the umbilical hernia defect with a
Richter's type of hernia. The bowel was reduced and the bowel
actually looked healthy after inspecting initially and after about 20
to 30 minutes at the end of the operation. It did look a little bit
bruise, but not gangrenous, not black. He also had a very small about
1 to 2 cm umbilical hernia.

We then placed another 5 mm trocar in the left
side of the abdomen and with some manipulation. I was able to reduce
the piece of bowel. This was a Richter type hernia where the
antimesenteric side of the bowel was kind of stuck within the hernia
defect. The bowel itself actually looked okay. There were no signs
any necrosis, no signs of any perforation, no signs of any black
areas. It was all very very pink, a little bit of red, a little bit
of bruise, but it looked like it was healthy. We decided to fix the
hernia and then come back and look at it again, so therefore we made
about a 3 cm supraumbilical incision, dissected down to the anterior
fascia. We encircled the hernia sac and resected the hernia sac.
This exposed the fascial defect, which about 1 to 2 cm in diameter.
We closed it with four interrupted 0 Prolene sutures with buried knots
primarily. We then sutured down the umbilical dermis to the fascia
with two interrupted 3-0 Vicryl sutures. This completed the umbilical
hernia repair that was incarcerated. We then looked back in
laparoscopically and looked at the bowel again, and the bowel looked
quite healthy and peristalsing
For any procedure that begins as diagnostic and turns into therapeutic, you can't bill for both; you can only bill for the repair. 49320 is the diagnostic code and since the exploration led to a repair, you'd have to code accordingly. Also, any procedure that begins as a laparoscopic and turns into an open procedure would get billed as open.

In your case, the patient had a strangulated umbilical hernia, which was repaired via an open procedure. Since this procedure was open from the start, obviously it'd be reported as open. Assuming the patient is at least 5 years old, I'd suggest 49587 Repair umbilical hernia, age 5 years or older; incarcerated or strangulated.

Regarding the laparoscopic manual reduction of the SB, I'm pretty sure that's included in the open repair as it's all part of the hernia defect. I also don't see it meeting the criteria for a 22 mod on the repair code. I may be wrong on this though.
From what I can see in the NCCI manual it seems like the laparoscopy done during/after the open procedure would fall under a scout procedure and not separately reportable. Maybe add a modifier 22 to the open hernia repair if it's significantly over and above the usual and submit with the op-note.

It would only be separately reportable for instance if the patient came in for a scheduled diagnostic colonoscopy and they found something, and it led to a decision to perform an open procedure (different from converting from closed to open)

2. If a laparoscopy is performed as a “scout” procedure to assess the surgical field or extent of disease, it is not separately reportable. If the findings of a diagnostic laparoscopy lead to the decision to perform an open procedure, the diagnostic laparoscopy may be separately reportable. Modifier 58 may be reported to indicate that the diagnostic laparoscopy and non-laparoscopic therapeutic procedures were staged or planned procedures. The medical record must indicate the medical necessity for the diagnostic laparoscopy.

3. If a laparoscopic procedure is converted to an open procedure, only the open procedure may be reported. Surgical laparoscopy nor a diagnostic laparoscopy code should be reported with the open procedure code when a laparoscopic procedure is converted to an open procedure.