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  1. #1
    Question 49000???
    Medical Coding Books
    Not sure what to do with this case. The patient was scheduled for repair of femoral hernia, but during the procedure was found NOT to have a hernia. So the "femoral" area was explored. Would 49000 be appropriate? My other problem is that 49000 is an inpatient only procedure?

    Procedure as follows:

    PREOPERATIVE DIAGNOSIS: Right femoral hernia.

    POSTOPERATIVE DIAGNOSIS: No femoral hernia found.

    OPERATIONS PERFORMED: Exploration of right femoral hernia.

    INDICATIONS: This 73-year-old male presented with a complaint of a bulge in the right groin area. He has had previous inguinal hernia repairs.

    FINDINGS: The femoral area was explored as was the inguinal canal area and no hernia was found.

    DESCRIPTION OF PROCEDURE: With the patient supine on the operating table and under general anesthesia, the right groin area was prepped with Betadine and draped in usual sterile manner for right inguinal surgery. A skin incision was made obliquely just at the inguinal ligament area. This was carried down through the subcutaneous tissue using electrocautery. The femoral area was explored. No hernia was found. The inguinal area was explored and no hernia was found there either.

    The subcutaneous tissue was then approximated with a running suture of 3-0 Vicryl in 2 layers and the skin was closed with a running subcuticular suture of 4-0 Monocryl.

    A sterile dressing was applied and the patient was then awakened, extubated, and taken to the recovery area in good condition. Estimated blood loss was minimal and he tolerated this procedure well.

  2. #2
    I would bill 49550-52.

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