Escision of infected abdominal wall mesh

nlbarnes

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Surgeon uses 11008 for the excision of the infected abdominal wall mesh. However, it's an add on code and the qualfying procedure was not done. I come across this alot.

Surgeon coded: 49060, 49560, 49568 & 11008
FINDINGS:
Infected mesh from previous umbilical hernia repair, in preperitoneal
position. Surrounding preperitoneal abscess. No communication
Of the abscess wih the abdominal cavity was noted. Multiple suture
granulomas around proline stitches. Significantly inflamed,
And swollen tissues, including fascia.

Bovie cautery was used to make a 9 cm vertical midline incision around
the umbilicus.
The incision was carried down with the help of Bovie cautery, until the
fascia was identified.

The fascia was incised on the midline, starting away from the umbilicus,
to establish clear anatomy.
The incision continued caudad, until the mesh was identified in the
preperitoneal position. Careful, and meticulous dissection
Was performed around the mesh, excising proline stitches, and performing
lysis of adhesions,
As the mesh was densely adherent to the fascia. Eventually the entire
mesh was mobilized and completely excised.
Approximately 7 mL abscess was noted around the mesh, and was completely
positioned in the preperitoneal space,
Without any evidence of communication with the peritoneal cavity. The
abscess was evacuated and the abscess cavity was irrigated with warm
normal saline solution. Wound 11042 be appropriate vs 11008?


The hernia defect was measuring 5 cm. the fascial defect was then
repaired with a running 0 PDS suture.
Adequate fascial closure was noted. The fascia was strong, edematous,
and thickened. 49560

a 5 x 6 cm AlloDerm mesh was then placed above the fascia, and secured to
the underlying fascia with multiple interrupted
0 PDS sutures. Good positioning of the mesh was noted. 49568
 
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+11008 has a note below it that states "When insertion of mesh is used for closure, use 49568"
+49568 is also an add on code which states "Use in conjunction with 11004-11006, 49560-49566"

As far as billing for the removal of the mesh, last time I read up on this (which has been a while), the rules go like this. If a surgeon is repairing a previous hernia in which mesh was placed and has subsequently become infected, you can't bill for the removal of the infected mesh that was placed in a previous hernia repair. On face value it seems unfair that you can't bill for a service that was performed, however the code for the hernia repair takes into consideration the fact that you will be removing the infected mesh and the RVUs reflect that, which leads to a higher reimbursement value. Essentially, "repair" includes any procedure done to fix it, eg, mesh removal. Some people try billing 49999 for the removal, which is very much wrong.

This is not the greatest comparison, but think about a surgeon removing a kidney. Clearly he/she has to have an approach to get there, but obviously we don't charge a separate code for the approach only.

There is a something that can possibly be done in circumstances where the "repair" (including the removal) required extensive work, "above and beyond"... say hello to mod 22. Of course the documentation would have to support it, but if it's justified, then I'd tack it on the repair code. I would watch out for over-use of the 22 though.

If it were ME, I'd 86 the removal code, and bill 49560(-22 if applicable) for the hernia repair (and mesh removal), 49060, 49568. I think adding a removal code of any kind, include 49999, would be the equivalent to double-dipping. If the surgeon has an issue with not billing the removal "because it took extra work," then it'd all come down to the surgical report describing the additional work so that a 22 could get added on, and he/she would essentially get paid for the "difficult" removal via the modifier and not a separate code. 2+2 equals 4, but 3+1 also equals 4, if you get what I mean.

If I can find the documentation about this online, I'll post it.
 
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