Hernia repair is a frequently performed procedure that commonly occurs in the outpatient setting. While hernias can be congenital or acquired, acquired hernias can be caused by a number of factors but are often a result of muscular strain or injury. In order to select the appropriate codes for the surgical procedure performed, there are a few key elements pertaining to hernias that need to be considered; the type of hernia, age of the patient, whether the hernia is initial or recurrent, the surgical approach (open or laparoscopic), if mesh is used during an open repair of an incisional or ventral hernia (mesh is included and not separately reportable in all other hernia repairs), and laterality, if appropriate.
Types of Hernias
Typically hernias occur when tissue protrudes through a weakness or defect in the abdominal wall and are categorized based on their location. The most common site for occurrence is the groin (inguinal) where a loop of intestine bulges through an opening of muscle in the inguinal canal. Femoral hernias may occur just below the groin in the middle of the thigh. In an umbilical hernia there is a protrusion of intestine and omentum through the abdominal wall near the naval. A hernia at the site of a previous surgical incision is referred to as an incisional or ventral hernia. Epigastric hernias are located in the mid-upper abdomen and a Spigelian hernia is a ventral hernia that occurs through the spigelian fascia. No matter where a hernia occurs within the abdominal wall, there is a defect within the muscle and pressure pushes the abdominal contents through that defect.
Hernias are further classified as reducible versus incarcerated or strangulated and as initial or recurrent. When reducible the hernia can be repaired non-surgically by manipulation, but will often be repaired surgically to prevent the possibility of incarceration. An incarcerated hernia is one in which the intestine gets trapped and is no longer reducible by manipulation and requires surgical repair. If the blood supply gets cut off in an incarcerated hernia it becomes strangulated and surgery may become emergent.
Coding and Reporting of Hernias
The codes for reporting a hernia repair are listed in the CPT manual under the section titled Hernioplasty, Herniorrhaphy, Herniotomy. Again, it is important to note not only the location of the hernia and whether it’s reducible, incarcerated/strangulated, initial or recurrent, you must also identify whether the surgical approach is open or laparoscopic. Mesh is often utilized in repair of the hernia to create a tension free repair which minimizes the risk for recurrence. The utilization of mesh is considered inherent to the surgical procedure with the exception of incisional or ventral hernias.
An incisional hernia often referred to as a ventral hernia is a type of hernia caused by an incompletely-healed surgical incision. These hernias most commonly develop from:
• Disruption along or adjacent to the area of the abdominal wall incision closure, and/or
• Tension, placed on the tissue as a result of suturing
When mesh is utilized in the repair of an open incisional or ventral hernia, CPT code 49568, Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair), would be separately reported. For facility reporting under OPPS, HCPCS Level II code C1781, Mesh (implantable) would be reported. Please note the removal of previously placed mesh during hernia repair would not be separately reportable as it would be captured in the CPT code for a “recurrent” hernia.
Use of modifiers:
When coding inguinal hernias, laterality must be taken into consideration. If a bilateral procedure is performed, it is appropriate to append modifier 50. When multiple hernia repairs occur during the same encounter or occur at separate sites, it is important to check the NCCI edits to see if the procedures are considered bundled. If bundled, and the documentation clearly indicate that the procedures are “separate and distinct,” modifier 59 may be appended if appropriate.
Reporting the correct codes for hernia repair, like all surgeries, is dependent on a thorough review of the operative report and querying the physician when key components; type of hernia based on location, whether initial or recurrent, reducible or incarcerated/strangulated, surgical approach, laterality if appropriate and if mesh was used in open incisional or ventral repair, are missing.
Here are a few previously published questions and answers regarding the appropriate reporting of hernia repairs.
A patient presents for repair of an umbilical hernia. The umbilical hernia sac was removed and the omentum was placed into the abdomen. Finger palpation revealed a small ventral hernia with a fascial bridge between both the umbilical and ventral hernias. The fascial bridge was transected making one large defect. The fascial defect was repaired with a mesh patch which was sutured in place. The patient tolerated the procedure well. Our facility wants to know whether it is appropriate to report the repair of two hernias through the same incision.
Assign CPT codes 49587, Repair umbilical hernia, age 5 years or older; incarcerated or strangulated, and 49561, Repair initial incisional or ventral hernia; incarcerated or strangulated or 49566, Repair recurrent incisional or ventral hernia; incarcerated or strangulated, for the procedures performed. Report CPT code 49568, Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair), for the mesh application. Append modifier 59, Distinct Procedural Service, to CPT code 49568 to identify that the mesh was utilized to repair the fascial defect as a result of the hernia repairs.
A woman with a long-standing history of morbid obesity is admitted for laparoscopic gastric bypass with Roux limb. The patient was also diagnosed with pelvic peritoneum adhesions and ventral hernia and had lysis of adhesions and hernia repair. What are the appropriate procedure code assignments for this case?
Assign CPT code 43644, Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less), or 43645, Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption, (if greater than 150 cm). The lysis of peritoneal adhesions would not be separately reported.
An 80-year-old patient presents to the hospital for same day surgery to repair an incisional hernia. During the hernia repair with prosthesis, the physician noted extensive small bowel adhesions and obstruction. Extensive adhesiolysis was also carried out. What are the appropriate codes for this case?
Assign CPT codes 49560, Repair initial incisional or ventral hernia; reducible, and 49568, Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection, for the procedures performed. According to the documentation submitted extensive lysis of adhesions was performed, therefore the lysis of adhesions would be separately reported with modifier 59 appended to the appropriate CPT code.