AHA Coding Clinic® for HCPCS - 2011 Quarter 4; ASK the EDITOR
Laparoscopic repair of right inguinal hernia
A 67 year old female patient presents for laparoscopic repair of a right inguinal hernia. A midline incision was created to repair the bladder. During the laparoscopic repair, a 5 mm hole was accidentally created. The bladder hole was closed in two layers and this injury was documented as a complication and considered to be significant. Should the bladder repair be reported in addition to the hernia repair? If so, what is the appropriate CPT code for suture repair of bladder injury performed during laparoscopic hernia repair? ...
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Article Overview
This premium coding article explains how to think about reporting a laparoscopic inguinal hernia repair when an unplanned bladder injury is repaired during the same encounter. It is intended for coders, billing staff, and revenue cycle professionals who work with surgical operative reports and CPT-based reporting. The article focuses on the circumstances described in the operative note, the related surgical service areas, and the CPT codes involved in the scenario.
Why This Topic Matters
Operative reports sometimes include additional repair work performed because of an intraoperative complication, and those situations can affect how services are coded and reported. Understanding the scope of the article helps readers determine whether they need guidance on hernia repair coding, incidental injury repair, or CPT selection for complex operative cases.
What You Will Learn
- How the article frames coding for a laparoscopic inguinal hernia repair with an associated bladder injury
- How the operative scenario is presented in relation to separate reporting considerations
- What CPT-focused guidance the article provides for the surgical procedures discussed
- How complication documentation can affect coding review for an operative case
Who Should Read This
- Medical coders
- Coding auditors
- Billing specialists
- Revenue cycle staff
- Surgery documentation reviewers
Codes Discussed
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