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Thread: Surgery Guidelines Clarification ?

  1. #1

    Default Surgery Guidelines Clarification ?

    AAPC: Back to School
    I have a couple questions concerning correct guidelines to follow in the follow scenarios & I cannot locate an answer to so hoping someone can help with an answer: When a patient presents for surgery for 1 issue, such as a tubal ligation & upon incising the umbilical area, an umbilical hernia is found & repaired. Is it correct to bill the patient for both procedures when the patient was only aware of the tubal ligation occuring?
    I'm also confused in the following case: patient presents for an umbilical hernia repair, upon incision a ventral hernia was also found & repaired. Do I code for the umbilical repair with a 22 modifier for an additional ventral hernia repaired? The ventral hernia repair has a higher RVU value so I'm confused on the proper guidelines to follow when multiple procedures are done but the patient is only aware of the 1 procedure being done.

    Thank you
    Jody Hecht

  2. #2


    1. Your patient should be signing a consent form that states something along the lines of "This is what the doctor plans to do, but that may change when he gets in there." My surgeon ALWAYS has them sign a consent form that states that even though he plans to do a laparoscopc procedure, if he begins the procedure and this turns out not to be feasible, he WILL do an open procedure. Unless the patient specifically asks to be woken up if anything unexpected happens, you should be covered. You may want to read the patient consent forms that your office uses very carefully to see if this is covered. Also, if your physician doesn't fix the hernia now, it'll only get worse after making an incision right next to it. It would be medically unsound for him to leave the hernia, since it would have a significant negative impact on the patient's ability to heal from the primary procedure. Having said that, whether or not you can bill depends on the hernia repair.

    2. Ventral hernia means a hernia on the front of the body. By that definition, the umbilical hernia is also a ventral hernia. Depending on how close together the two hernias were, you would either bill one ventral hernia repair code, or bill both hernia repair codes with modifier 59s. You would only do this is it is very clearly documented that both hernias were repaired via seperate incisions, or were two seperate complex repairs. Reducible Umbilical hernia repairs as a secondary procedure are frequently not reimbursed because they are considered to be part of the abdominal closure, but you can probably get reimbursed for an incarcerated Umbilical Hernia repair.

    Hope that helps

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