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nyckimmie

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Hello, I am an Outpatient Coding Educator for facility billing. My Quality Auditor and I are disagreeing on whether or not to abstract an ICD for the right hernia mentioned at the end of the procedure. The rest of the chart (h&p, order, radiology, consent, etc.) makes no mention of a rt hernia only the LT. We have sited many coding clinics, ICD guidelines to each other and still can't agree on if the coder should be dinged. Would you pick up the RT hernia as an additional dx or would you consider it incidental and why? If anyone would care to give your thoughts, we would appreciate it a lot. thanks!
Pre-procedure Diagnoses: Non-recurrent inguinal hernia of left side without obstruction or gangrene [K40.90]
Post-procedure Diagnoses: Non-recurrent inguinal hernia of left side without obstruction or gangrene [K40.90]
Procedures: PR LAPARO HERNIA REPAIR INITIAL [49650 (CPT®)]
OPERATIVE REPORT
Specimen(s) sent to Pathology: none
Complications: none
PROCEDURE IN DETAIL
Patient positioned on the table in supine position a universal timeout was performed. Laparoscopic access was obtained initially with a 5 mm insufflating port via the left upper quadrant 2, 8 mm ports were inserted 8 cm from the midline approximately 2 cm above the umbilicus bilaterally, the 5 millimeter port was converted to an 8 millimeter robotic port as well. The patient was placed in 15° of Trendelenburg the Xi robot was being used
At the console we began dissection on the left there was an indirect hernia noted we opened the peritoneum cephalad to the inguinal canal and dissected the peritoneum off of the structural abdominal wall taking care to avoid injury to the inferior epigastric vessels or any of the spermatic cord structures once we had the peritoneum dissected down we dissected the vas and vasculature to the retroperitoneal point of emergence. And once it was a good space to place our mesh a large mid weight 3-D Max mesh was requested we closed the hernial defect by approximating the conjoined tendon to the iliopubic track. This was done with 2-0 Vicryl robotically once this was completed the mesh was positioned. 2-0 Vicryl again was used to tacked the mesh to the abdominal wall at the Cooper's ligament at the level of the repair and high on the rectus fascia. Lateral stitches were avoided. The peritoneum was restored using an absorbable 2-0 V LOC suture. We inspected and the repair looked quite good with the mesh flush against the abdominal wall.

There was a similar hernia on the right side which had remained asymptomatic and we had agreed not to repair.

After undocking in the cannulating all the incisions were closed using 4-0 Monocryl subdermal. 0.5% bupivacaine was injected in the preperitoneal space. Exparel and 0.5% bupivacaine with epinephrine was injected at all the incision sites for postoperative analgesia.
Patient tolerated this procedure well and was escorted to the recovery
 
The provider specifically documented it and spoke to the plan of agreeing not to repair. I probably would have reported it. I would cite ICD-10-CM Guidelines, Section IV, G. ..."List additional codes that describe any coexisting conditions." and J. "Code all documented conditions that coexist."
I see it both ways though, I can see how it could be incidental and not reported too. Especially since it's aysmptomatic and not on anything else in the chart. Seems odd though because if they agreed not to repair it, they had to know about it preoperatively. He didn't say it complicated care and no complications stated in header.
I probably wouldn't ding the coder but use it as a teaching opportunity because it seems to be one of those that could go either way. I don't think there's a firm yes or no answer on it.
 
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