Open Hernia with laparoscopy mesh repair cpt code

uwalia

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My surgeon did an open umbilical hernia repair and then placed mesh laparoscopic. Which CPT code open hernia repair 49587 or laparoscopic hernia repair 49653 will work. Please help.
 
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49653 is for laparoscopic repair and mesh insertion, so I don't see how that would be possible as the repair was open.

I assume the hernia was incarcerated or strangulated and that the patient is age 5 years or older if you're considering 49587. If so, then that's the only code you can bill as "the use of mesh is not separately reported" per the CPT guidelines for that code.
 

uwalia

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Thanks for the reply, but CPT guidelines allow separate billing for mesh for ventral or incisional hernia and not for umbilical. Any thoughts on why umbilical hernia repair is not compensated extra for mesh.
 
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Thanks for the reply, but CPT guidelines allow separate billing for mesh for ventral or incisional hernia and not for umbilical. Any thoughts on why umbilical hernia repair is not compensated extra for mesh.

I think it has to do with the actual purpose of the mesh. The codes 49560-49566 (incisional hernia repair) are the only ones that permit the use of the separate mesh code +49568; if you set those aside for a second and look at the remaining procedures, mesh is used for a variety of reasons, generally speaking.
For example, code 49587, the umbilical hernia repair, the clinical description I'm reading states mesh can be used to repair large defects. Or code 49553, femoral hernia repair, the description says mesh may be used to prevent reoccurrence.

However, for 49561, incisional hernia repair, the description reads as "...dissects down through the scar tissues, removing adhesions as needed and identifying the hernia sac. He opens the hernia sac to check the incarcerated or strangulated hernia sac contents. He identifies the extent of the live tissue remaining in the hernia. If the contents are healthy enough to continue the normal functions, he reduces the hernia sac and places it back in proper anatomical position. If the patient requires intestinal resection or mesh placement, that service is separately reportable." So the mesh isn't being used to close up a large defect or to prevent reoccurrence; it reads more like the mesh is being used to sort of hold everything together until it "heals up," if it's even able to be placed at all. (I also checked the laparoscopic repair for this 49655, and it states the mesh could be used to prevent reoccurrence, nowhere near what the open procedure indicates)

I understand that to mean that in the previous examples, the mesh was placed for reasons far less severe than why it's being used in the last example. So including the mesh in the bulk of the codes seems appropriate to me, considering the fact that it's being used to complete or finalize the repair. But if it's being used to support or hold together parts of the inside of your body :eek:, that's a whole different story.

It's also important to remember that, although you can't report the mesh separately, if the need for the mesh seems above what would be considered a normal part of a repair, there's no reason you couldn't try to use mod 22 if the documentation supports it and ask for additional reimbursement. The guidelines say you can't bill the codes together; it doesn't say you can't bill with a 22.

Along those same lines, if a surgeon does a recurrent hernia repair which requires removal of old mesh, you can't code the removal separately either. It's also considered a "component" of the "repair". Some people try to use +11008 or an unlisted code, which is also not permitted. Last I knew, the suggestion was to put a 22 mod on the repair if the mesh removal was significant enough to meet the standards for it and then include a note on the claim about it. But again, you can't really do a repair if you don't take out the problem first.

Although I may be publicly shamed for saying this, I kind of agree with the coding.
 

uwalia

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Thanks a lot

Thanks for taking the time to explain with great detail. I am sure many people like me will learn by reading your reply.
 
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