Wiki Documentation for hernia repair codes

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sjcarlile07

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Does anyone know if there is any documented information about what is required as far as where the hernia defect size MUST be documented? My surgeon documents it in his pre-op office visit note for 2 reasons; 1. we have to have the size to know what code to get prior auth for, and 2. for documentation of the pre-surgery size.
I have received a Humana post-payment review denying billing 49593 because they are saying that the pre-op size is not documented. I sent them the office visit note, which also suffices for the H&P for the admit, which has the size, to appeal the denial. They are still denying. I don't know if they are truly denying because the hernia ended up being .5 cm larger than the pre-surgery size once the surgeon did the surgery and they are just not wanting to pay for the higher code. Surely they are not saying that you have to bill for the pre-surgery size regardless of what is found during the surgery, right???
I can't find anything about where there is a requirement that this size be documented in a specific place.
I am thankful for any help.
 
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I can't speak specifically about hernia codes, but I can speak to planning (and authorizing) one CPT, but then actually needing to code another.
For example, my docs do a lot of laparoscopic hysterectomies. There is one code for uterus < 250gms. There is a separate code for uterus >250gms. OBVIOUSLY we can't weigh the uterus prior to the procedure. In fact, until the final pathology report comes back (sometimes 3 weeks later), we do not know the weight of the uterus. We authorize 58571 for < 250gms. Every once in a while, the uterus weight comes back as > 250gms and bill 58573. About 95% of the time, insurances will pay the 58573 with no additional intervention needed. For the 5% denials, we write an appeal letter explaining the fact that we cannot weigh the uterus prior to surgery and those get paid almost all the time. There is 1 specific carrier that states if we authorize a specific CPT, we have 3 business days after the surgery to contact the insurance and change the authorization CPT. Three business days later, the uterus hasn't even been processed by pathology and there is no way we would know a different CPT even needs to be authorized. We appeal until it is paid or all appeal methods have been exhausted.
So, Humana may have a policy that if you authorize the smaller size and at the time of the surgery realize it is a larger size, you should be contacting them and changing the authorization at that time. If so, in my opinion, this is just a way for them to deny payment on medically necessary procedures for minor administrative reasons.
I do NOT bill what I know is an incorrect code just in order to receive payment, as that is clearly incorrect and non-compliant. I use the proper codes for what was performed and appeal.
 
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I have not seen any specific info about where to document the hernia size. We are also having issues with Humana. I suggest to our surgeons to document the hernia size in the Findings section. The reason I suggest this is because Humana has audited every single hernia repair and when the measurement is in the Findings section ONLY, they will pay the claim. If it is in the body of the op note, the surgeon needs to make it very clear that measurement was taken without opening the hernia defect or prior to opening the hernia defect.
Also, I'm wondering if there is a disconnect between what CPT and American College of Surgeons is saying (measurement must be made before opening the defect) and what payers are hearing (measure before making any incisions)?? This is what our surgeons are saying: often times the hernia defect is not entered/opened during the repair as it is often not necessary to enter the peritoneum.
We also document it in the office visit note for prior-auth reasons.
 
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We're having this issue with UHC as well. The size was in the preop diagnosis but since it wasn't "measured before opening" they denied the claim stating the size wasn't documented.
 
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