Wiki Hernia Surgery

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tch678

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My surgeon did multiple abdominal procedures. Medicare has paid for all except the 49591 (Hernia Repair)x2. Patient had a Incarcerated Ventral Hernia and Incarcerated Umbilical Hernia. They both have the same CPT code of 49591. I billed the 49591 with 2 units and ICD 10 K43.6 and K42.0. Medicare denied for the units. How would you code this to be paid?
 
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If you read the description and notes for 49591, you should notice some issues with your use of 49591 x2.
49591 Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible
Notes:
Codes 49591-49618 describe repair of an anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian) by any approach (ie, open, laparoscopic, robotic). Codes 49591-49618 are reported only once, based on the total defect size for one or more anterior abdominal hernia(s), measured as the maximal craniocaudal or transverse distance between the outer margins of all defects repaired. For example, "Swiss cheese" defects (ie, multiple separate defects) would be measured from the superior most aspect of the upper defect to the inferior most aspect of the lowest defect. In addition, the hernia defect size should be measured prior to opening the hernia defect(s) (ie, during repair the fascia will typically retract creating a falsely elevated measurement).

When both reducible and incarcerated or strangulated anterior abdominal hernias are repaired at the same operative session, all hernias are reported as incarcerated or strangulated. For example, one 2-cm reducible initial incisional hernia and one 4-cm incarcerated initial incisional hernia separated by 2 cm would be reported as an initial incarcerated hernia repair with a maximum craniocaudal distance of 8 cm (49594).

Inguinal, femoral, lumbar, omphalocele, and/or parastomal hernia repair may be separately reported when performed at the same operative session as anterior abdominal hernia repair by appending modifier 59, as appropriate.

Codes 49621, 49622 describe repair of a parastomal hernia (initial or recurrent) by any approach (ie, open, laparoscopic, robotic). Code 49621 is reported for repair of a reducible parastomal hernia, and code 49622 is reported for an incarcerated or strangulated parastomal hernia.

Implantation of mesh or other prosthesis, when performed, is included in 49591-49622 and may not be separately reported. For total or near total removal of non-infected mesh when performed, use 49623 in conjunction with 49591-49622. For removal of infected mesh, use 11008.

1) 49591 specifies HERNIA(S). The notes state to report once with instructions about how to properly measure the 2 abdominal hernias.
2) 49591 also specifies REDUCIBLE, but your diagnosis states INCARCERATED

Hope that helps!
 
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csperoni said:
If you read the description and notes for 49591, you should notice some issues with your use of 49591 x2.
49591 Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible
Notes:
Codes 49591-49618 describe repair of an anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian) by any approach (ie, open, laparoscopic, robotic). Codes 49591-49618 are reported only once, based on the total defect size for one or more anterior abdominal hernia(s), measured as the maximal craniocaudal or transverse distance between the outer margins of all defects repaired. For example, "Swiss cheese" defects (ie, multiple separate defects) would be measured from the superior most aspect of the upper defect to the inferior most aspect of the lowest defect. In addition, the hernia defect size should be measured prior to opening the hernia defect(s) (ie, during repair the fascia will typically retract creating a falsely elevated measurement).

When both reducible and incarcerated or strangulated anterior abdominal hernias are repaired at the same operative session, all hernias are reported as incarcerated or strangulated. For example, one 2-cm reducible initial incisional hernia and one 4-cm incarcerated initial incisional hernia separated by 2 cm would be reported as an initial incarcerated hernia repair with a maximum craniocaudal distance of 8 cm (49594).

Inguinal, femoral, lumbar, omphalocele, and/or parastomal hernia repair may be separately reported when performed at the same operative session as anterior abdominal hernia repair by appending modifier 59, as appropriate.

Codes 49621, 49622 describe repair of a parastomal hernia (initial or recurrent) by any approach (ie, open, laparoscopic, robotic). Code 49621 is reported for repair of a reducible parastomal hernia, and code 49622 is reported for an incarcerated or strangulated parastomal hernia.

Implantation of mesh or other prosthesis, when performed, is included in 49591-49622 and may not be separately reported. For total or near total removal of non-infected mesh when performed, use 49623 in conjunction with 49591-49622. For removal of infected mesh, use 11008.

1) 49591 specifies HERNIA(S). The notes state to report once with instructions about how to properly measure the 2 abdominal hernias.
2) 49591 also specifies REDUCIBLE, but your diagnosis states INCARCERATED

Hope that helps!
Click to expand...
what about when the pt has an open umbilical (incisional) and supraumbilical hernia (ventral) repaired at the same time, but 2 different incisions were made? Do you still only use one code?


A curvilinear incision was made below the umbilicus overlying her previous incision. Subcutaneous tissue was dissected with electrocautery and carried down to the fascia. The umbilical stalk was
densely adherent to the fascia. A small defect was made in the umbilical stalk during division. We suture this closed on the inside using 3-0 Vicryl in an interrupted fashion. The hernia defect measured
approximately 0.5 cm in size. There was nothing protruding through this defect. It was closed primarily with 0-Nuralon in an interrupted fashion. The umbilical stalk was tacked down again using 3-0 Vicryl. We then turned our attention to the supraumbilical hernia. A incision was made directly over the palpable lump after local anesthetic was injected. A large piece of fat was protruding through the defect here. This was dissected free from the surrounding tissue bluntly. The fat was ligated at the base with 3-0 Vicryl, then divided sharply and reduced back into the abdomen. The defect here measured about 0.4 cm in diameter. This was closed with 0-Nuralon. Skin edges were closed with 4-0 Monocryl in a subcuticular fashion. Dermabond was placed over the top of the incisions.
Sponge and needle counts were correct. The patient tolerated the procedure well with no apparent complications and was taken to recovery in good condition.
 
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Specifically:

Measuring Hernia Defect(s)​

Codes 49591–49596 and 49613–49618 are reported only once, based on the total defect size for one or more anterior abdominal hernia(s). In addition, the total hernia defect size should be measured before opening the hernia defect(s) because during repair the fascia typically will retract, creating a falsely elevated measurement. Hernia measurements are performed either in the transverse or craniocaudal dimension. The total length of the defect(s) corresponds to the maximum width or height of an oval drawn to encircle the outer perimeter of all repaired defects. If the defects are not contiguous and are separated by greater than or equal to 10 cm of intact fascia, total defect size is the sum of each defect measured individually. Without a total size indicated, coders may be inclined to report the hernia repair code for the smallest defect. Therefore, it will be very important to document the total defect size in the operative report so coders will know which code to select.
 
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