Can you code a hernia repair in addition to another abdominal procedure performed during the same surgery? It depends on the relationship between the site of the hernia and the incision for that abdominal procedure.
Valuable guidance on this topic can be found in the NCCI Policy Manual, Chapter 6, section E.4, which states: “If a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair (e.g., CPT codes 49560-49566, 49652-49657) is not separately reportable.
The hernia repair is separately reportable if it is performed at a site other than the incision and is medically reasonable and necessary.”
As you can see, we first need to identify if the hernia repair occurs along the incision line for another abdominal procedure. Note that this incision could be a large open incision such as a midline incision or it could be a smaller incision to place a port for a laparoscopic procedure. Either way, if the hernia is along the incision site, you cannot report the repair separately. Why? The revenue associated with every CPT code for an open or laparoscopic abdominal procedure already gives the surgeon credit for opening and closing the abdomen. This makes sense because you cannot perform an open or laparoscopic procedure of the abdomen without making some kind of incision in the abdominal wall and then repairing that incision. A hernia is a defect in the wall of a body cavity that allows the organs to protrude from their normal location. In the case of hernias along the abdominal wall, you have a defect (or an abnormal opening) in the layers of the abdominal wall. The surgeon is already being paid to make an incision through the layers of the abdominal wall to reach the abdominal cavity and the organ(s) requiring surgery. So if there is a defect there already, and the surgeon makes an incision through that defect, part of the abdominal wall was already open for him. When closing, the surgeon then has to suture or staple all the layers of the abdominal wall. In doing so, he will incidentally repair any hernia defect in the layers of the abdominal wall along that incision. For this reason, hernia repairs at the site of incisions for another abdominal procedure become part of opening and closing the abdomen. Since the surgeon is already paid to open and close the abdomen when reporting the CPT for the other intra-abdominal procedure he just performed, reporting the hernia code for a repair in that same location would be “double dipping” and reporting the same work twice.
You can report a hernia repair code and a code for an intra-abdominal procedure together if the hernia is repaired at a separate site through a separate incision from the open or laparoscopic incisions used for the intra-abdominal procedure. In this case, there is no “double dipping” on the opening and closing of the abdominal wall because the intra-abdominal procedure requires an incision into the abdomen and repair of the abdominal wall, and the hernia at a separate site also requires an incision into and repair of the abdominal wall so there is distinct work being performed. The hernia repair must be medically necessary and not incidental as well per this guideline – ensuring there is medical necessity is a given for any procedure we code, though.
Finally, you may notice that there are specific ranges of CPT codes listed in this guideline from the NCCI Policy Manual (49560-49566 and 49652-49657). Many coders assume that because there are specific code ranges listed that the guidelines only apply to hernia repairs that would be reported with these codes. However, the code ranges are preceded by an “e.g.” which means “for example.” So this guideline is not restricted only to ventral/incisional hernias. It might also apply to an umbilical hernia, epigastric hernia, or other more specific hernia repairs that are reported with different CPT codes when those repairs occur along an incision for another intra-abdominal procedure. These hernia repairs would be bundled when performed along the incision line for open or laparoscopic abdominal procedures for the same reasons explained above.
Sources: NCCI Policy Manual for Medicare Services – Effective January 1, 2020: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd
