multiple hernia repair question


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Patient had 4 hernias fixed within the same operative session, same incision. Would the CPT 49561 just be billed once since one incision? I am aware that I can use a -22 modifier but the doctor does not state in the op note how much more time he spent on the sx than if there were just one hernia repair. He also did an excision and release of the "extensive abdominal scar" which may also justify a -22 since that procedure is bundled into the primary sx. Here is the scrubbed op note. Let me know what you think.


PREOPERATIVE DIAGNOSES: Painful, irritative, and swollen incisional hernia with painful irritative dysmorphic abdominal scar mass and scar contracture.

POSTOPERATIVE DIAGNOSES: Extensive multiple incisional hernias, incarcerated, with irritative dysmorphic scar contracture with scar mass of the abdominal wall.

PROCEDURES PERFORMED: Exploration with reduction and repair of four incarcerated incisional hernias. Excision of the calcified fibrotic scar masses of the anterior abdominal wall and repair of the multiple incisional hernias with muscle flap component separation and placement of Strattice implant 20-cm x 16-cm in size, and excision and release of the extensive abdominal scar and scar contracture and wound closure with fasciocutaneous flap.


INDICATION: This is a 46 years old female in general good health who had uneventful abdominal surgery with an extensive midline incision from the xiphoid to the pubic area along with multiple scars from the previously tensioned suture placement. The patient now complains of several areas of bulging, painful, irritative, lumpy masses and with extensive abdominal scar deformity and scar contracture, and the patient desired to have the above improved. Planned procedure, risks, complication, alternative treatment, potential benefit, and possible need for further surgery and therapy were all explained and discussed in full detail with the patient. Shortly, risk of asymmetry, deformity, pain, numbness, bleeding, scar, infection, fluid collection, residual recurrence of problem, non-improvement, loss of skin, loss of umbilicus, loss of function, delayed wound healing, and unsatisfactory appearance of size, skin break, scar outcome, etc. were discussed. No assurance of success or possible outcome was given. She understood the above and accepted the above and requested us to proceed.

PROCEDURE: The patient was taken to the operating room and placed in supine position. After adequate general anesthesia was obtained, the patient was then prepped and draped in the usual sterile fashion. An excision and release of the painful irritative dysmorphic scar measuring 30 cm x 4 cm in size was then excised from the entire midline where she had the previous abdominal surgery. This scar was then excised away from the surrounding adhesion tissue and the scar contracture was excised and released down to soft healthy bleeding tissue. She was also noted to have five areas of fibrotic calcified scar masses from the previous surgery with foreign body reaction from the previous suture. These were then released from the surrounding adhesion tissue and excised down to soft healthy bleeding tissue. Dissection of the anterior abdominal wall was carried out and the patient noted to have four areas of incarcerated incisional hernia with one area of very thin and very _____(6:35) anterior abdominal wall and the fascia. All the hernia sac was then dissected out from the surrounding adhesion tissue and then the sac was then excised and the incarcerated omentum and preperitoneal fat was then reduced and returned into the anterior abdominal cavity. Afterward, the repair of these four areas of hernia was then performed with a muscle flap and with component separation. An incision was made on the lateral side _____(7:45) right side and left side over the external oblique muscles and then the rectus muscles and was then advanced toward the midline and the extensive fascial defect was then repaired with #1 Ethibond suture in a figure-of-eight fashion. Further the fascia on the top of this first layer repair via muscle flap was then performed by imbricating the rectus fascia further on top of this first layer repair and this imbrication was done with a #0 Ethibond suture in figure-of-eight fashion also. Afterward, a 20-cm x 16-cm Strattice implant was then placed over the entire abdominal wall and superiorly over the midline repair and this was then maintained in place with #0 Ethibond suture in horizontal mattress fashion. After the placement of the Strattice implant, we were able to obtain a very tight and firm anterior abdominal wall reconstruction. Hemostasis was again obtained. Irrigation was then done and then 1 g of vancomycin antibiotic powder was then sprinkled into the entire abdominal field and then a Jackson-Pratt drain was placed into the abdominal operative site and then brought out via separate stab wound incision. In order to close this extensive abdominal wound after the previous scar had been excised, a fasciocutaneous flap was then elevated on both the right side and left side maintaining as many vascular perforators as possible and then the fasciocutaneous flap was then advanced and rotated toward the midline and we were able to obtain a wound closure without any tension noted. The wound closure was then completed in multiple-layer plastic closure with #0-Vicryl for the fascial layer and the subcutaneous tissue and the skin was then closed with 4-0 PDS suture. Bulky fluffy dressing was then placed and procedure was then terminated. The patient tolerated the procedure well and she was then taken to recovery room in satisfactory condition.

15734 x 3

is what i'm coming up with.