Hernia repairs are a procedure that all general surgery coders will encounter many times in their career. Understanding what a hernia is and the different types of repairs that may be performed will help you ask the right questions to find the keys in your operative report and code this commonly-performed procedure correctly.
A hernia is simply a weakness in the muscle of the abdominal wall, the groin, the thigh, or the diaphragm that allow organs to become displaced. The organ that most often protrudes through this muscle weakness is the intestine, but the omentum,the ovaries, the testicles, and even parts of major abdominal organs like the stomach can protrude through a hernia defect depending on where the hernia is located and how large the area of weakness (also known as a hernia defect) is. When coding hernia repairs, I typically ask myself six key questions to ensure I select the correct CPT code.
Question #1: “What type of hernia is being repaired?” The “type” of hernia refers to the name of the hernia based on where it is located. Below are some hernias you may see:
- Ventral hernia: A hernia that occurs in the front of the abdominal wall typically near the middle of the abdomen
- Incisional hernia: A specific type of ventral hernia that occurs in the same location as a previous incision used for abdominal surgery. This type of hernia occurs due to weakness in the abdominal wall muscles because of the old incision.
- Inguinal hernia: A hernia that occurs in the inguinal canal (in the groin area)
- Sliding hernia: A hernia in the groin area where the walls of the colon (typically the cecum or the sigmoid colon) form part of the hernia sac
- Umbilical hernia: A hernia that occurs in the umbilicus typically due to an imperfect closure of the umbilical stalk
- Epigastric hernia: A hernia that occurs in the upper middle portion of the abdomen (above the umbilicus)
- Femoral hernia: A hernia that occurs in the thigh when an internal organ from the groin protrudes through a weakness in the thigh muscles
- Hiatal hernia: An internal hernia that occurs when a defect in the diaphragm allows the stomach to protrude up into the chest cavity
Question #2: “Is the hernia reducible or incarcerated?”
- A reducible hernia is a hernia where the organ(s) protruding through the hernia defect can pass through the defect and then back into their normal location in the abdomen/pelvis with ease.
- An incarcerated hernia is one in which an organ(s) have protruded through the hernia defect but then become “stuck” in the displaced position in the hernia sac and cannot return to their normal location in the abdomen/pelvis.
- A strangulated hernia is a type of incarcerated hernia where an organ(s) have become “stuck” in the displaced position in the hernia sac and blood flow has been cut off to the organ as a result of becoming stuck in the hernia sac.
- A gangrenous hernia is a more severe type of incarcerated hernia where the organs have been strangulated (trapped without blood flow) for enough time that the tissue of the organ(s) trapped within the hernia sac begin to die.
While a reducible hernia can typically be repaired electively when the patient/surgeon agree it is time to repair the defect, incarcerated, strangulated, and gangrenous hernias are typically medical emergencies that require urgent surgery to prevent further damage to the abdominal and pelvic organs that are trapped in the hernia sac. From a coding perspective, reducible hernias are usually reported with one CPT code while incarcerated hernias are usually reported with a different CPT code. Incarcerated, strangulated, and gangrenous hernias are all coded the same way because all of these hernias are types of incarcerated hernias – remember strangulated and gangrenous hernias are just more severe types of incarcerated hernias where the organs trapped in the hernia sac are not receiving blood flow and/or contain tissue that is dying due to the lack of blood flow.
Question #3: “What is the approach to the hernia repair?”
The approach to a surgical procedure is the way in which the surgeon gains access to the organ/structure requiring surgery. Hernia repairs can be performed in one of two ways:
- An open approach involves an incision to gain access to the hernia defect/sac and directly visualize the hernia to perform the repair.
- A laparoscopic approach involves multiple small incisions followed by insertion of small ports that allow the physician to inflate the abdomen with air and pass a scope into the ports to see the hernia defect indirectly. The surgeon then repairs the defect using instruments passed through the ports while visualizing the hernia through the scope.
Question #4: “Is this the initial hernia repair or a subsequent hernia repair in this same site?”
Some hernia repair codes contain the words “initial” or “recurrent” in their code descriptions. There are different CPT codes for initial and recurrent hernia repairs because a recurrent hernia repair is typically more difficult due to scar tissue in the area and the increased weakness of the muscles because of the prior incision in the area.
Question #5: “Did the physician use mesh to repair the hernia?”
For open ventral and incisional hernia repairs, using a piece of mesh such as Vicryl mesh or allograft mesh to repair the hernia allows you to add an additional code (CPT 49568) in addition to the hernia repair code. For all other hernia repairs (inguinal, umbilical, laparoscopic ventral, etc.), the placement of mesh is already included in the hernia repair code when performed and cannot be reported with an additional code.
Question #6: “How old is the patient?”
For open inguinal hernia repairs, there are different codes for repairs performed on infants, children, and adults. When the surgeon is working in the smaller space in the inguinal canal of an infant or child, the surgery is harder than when the surgeon is working in the larger space in the inguinal canal of an adult. That is why CPT offers different codes based on patient age for this particular type of hernia repair.
Asking yourself these six questions will help you identify the keys in the operative report to choose the correct CPT code. In our next article, we will look at some specific examples of notes for different types of hernia repairs and apply this method to each note to choose from among available codes options.
