Wiki questions on hernia coding :)

[BABS37]

Hi all! The only verbiage I am getting for my hernia repairs are the following:

-Laparoscopic bilateral inguinal hernia repair
-Laparoscopic bilateral inguinal hernia repair (extraperitoneal)

How do I tell if they are strangulated or incarcerated; initial or subsequent; redicible? I thought maybe these fell in the 49654-49656 area but have no clue as to which one he did... Do I have to have my surgeon state these in his Op note?

Any help is appreciated!

 

[missy874]

It should be within the body of the op note. If its not noted, then I wouldnt code as such. Never take the name of the procedure from the beginning of the report, often our providers shortchange themselves that way. Sometimes you even find other procedures that can be billed with the original or a more extensive one than stated by reading the body.

 

[BABS37]

Oh I don't ever code by what the surgeon declares his procedure as- I code strictly by the Op note documentation only. But what I need to know is, am I looking for a statement that says the blood supply is cut off to represent strangulated or 'what' can or cannot be returned to the abdominal cavity to represent incarcerated or reducible? I don't know what it is I am looking for so that's what I'm trying to ask- does my doctor have to state those exact words? I have a remote coder that helped with these as a temp short term and I have identical Op notes basically and she coded them as one reducilbe and one as initial- I can't figure out why or how or what it was she was looking at to figure out the difference so that I can code the rest of these surgeries.