I need help coding this surgery. The surgeon states that he did not find a hernia so would I still bill a 49505 or is there a more appopriate code?
Thanks,
Jen
The patient was prepped and draped in routine fashion. A right groin incision was placed. The incision carried down through the skin and subcutaneous tissue. The leg had been marked and the operative site had been confirmed preoperatively. The external oblique fascia was identified and opened in the direction of the external ring. The cord contents were encircled with a Penrose drain. I confirmed the spermatic cord structures and did a careful search for evidence of an indirect hernia sac. The cord structures were definitely seen and identified, and I could not readily find an indirect hernia sac. I probed the floor of the inguinal canal and this appeared patent. I did not open the floor. I did see some lymphatic and fatty fibrous tissue located superior to the external oblique fascial layer. This was ligated, but I did not see anything else specifically that could be a hernia. No mesh was utilized. The wound was closed in layers of absorbable sutures. A total of 10 cc of 0.25% Marcaine was injected.
Thanks,
Jen
The patient was prepped and draped in routine fashion. A right groin incision was placed. The incision carried down through the skin and subcutaneous tissue. The leg had been marked and the operative site had been confirmed preoperatively. The external oblique fascia was identified and opened in the direction of the external ring. The cord contents were encircled with a Penrose drain. I confirmed the spermatic cord structures and did a careful search for evidence of an indirect hernia sac. The cord structures were definitely seen and identified, and I could not readily find an indirect hernia sac. I probed the floor of the inguinal canal and this appeared patent. I did not open the floor. I did see some lymphatic and fatty fibrous tissue located superior to the external oblique fascial layer. This was ligated, but I did not see anything else specifically that could be a hernia. No mesh was utilized. The wound was closed in layers of absorbable sutures. A total of 10 cc of 0.25% Marcaine was injected.