One of the more notable CPT® changes impacting surgical coders in 2023 is the overhaul of the CPT codes for repair of ventral, incisional, umbilical, spigelian, and epigastric hernias. CPT codes 49560-49561, 49565-49566, 49568, 49570, 49572, 49580, 49583, 49585, 49587, 49590, and 49652-49657 have all been deleted. In their place, fifteen new CPT codes in range 49591-49596, 49613-49618, 49621-49622, and 49623 were created.
I am not going to list out each code and all their descriptions in today’s article because you can find those in the CPT manual and your coding software. Instead, I want to dedicate this article to outlining what’s new, what remains the same, and what you can partner with your surgeons on right now to ensure their documentation is detailed enough to code abdominal wall hernia repairs come January 1st.
What’s the Same in 2023?
First, I think it’s useful to look at what is not changing in 2023. It is always good to find the familiar territory when learning new codes and rules and trying to navigate how to pull what you need out of an operative report:
- Initial vs. recurrent: The new codes are still differentiated by initial versus recurrent in the code descriptions just as they are today. Therefore, this detail is still important for surgeons to document and for coders to consider in their final code selection.
- Reducible vs. incarcerated: The new codes still categorize hernias as reducible versus incarcerated. As a quick refresher, reducible hernias are ones where abdominal organs protrude through the defect in the abdominal wall and can pass through that defect and then back into the abdominal cavity. In contrast, incarcerated hernias are ones where the abdominal organs protrude through the defect in the abdominal wall and become “stuck” in that displaced position in the hernia sac and are unable to return to the abdominal cavity. Strangulated and gangrenous hernias are specific types of incarcerated hernias where the abdominal organs get stuck to the point that there is a lack of blood flow to the organs or, in severe cases, a death of the tissue. So, again, surgeons should still document whether a hernia is reducible or incarcerated, and coders should still consider these details in their final code selection.
- Component Separation Coding: Component separations are complex abdominal wall reconstructions that were not valued into the new hernia repair codes and are still coded separately in addition to the hernia repair. CPT 15734 is coded for each flap created; therefore, if the component separation is performed bilaterally, code CPT 15734 for the first side and then CPT 15734 again with modifier 59 or XS for the second side (final modifier is based on payer guidelines).
- Inguinal, femoral, and lumbar hernia coding: The codes, descriptions, and guidelines for coding inguinal, femoral, and lumbar hernias are unchanged in 2023. The 2023 changes impact only anterior abdominal wall hernias including ventral, incisional, umbilical, spigelian, and epigastric hernias. So, for these other types of hernia repairs, you still need all those key details like approach, age, initial vs. recurrent, and reducible vs. incarcerated as outlined in CPT just as you do today.
What’s new in 2023?
Pretty much everything else! In all seriousness, though, below is a list of some key changes that will impact both the required documentation and the final coding of these services:
- The “type” of hernia is no longer a factor in coding: The new codes remove reference to specific types of hernias such as ventral, umbilical, epigastric, spigelian, and incisional and instead use a single term of “anterior abdominal wall hernia.” In some ways, this makes coding easier. For example, we can skip scrutinizing an operative report trying to determine if a hernia is umbilical or ventral because there is a supraumbilical extension – it’s all the same code. With that said, documentation should still list the type of hernia in these terms for best practice just from the perspective of having a complete note with good clinical details. But you could still code the hernia repair if you have documentation that minimally supports an anterior abdominal wall hernia repair.
- One hernia repair code per surgery: If there are multiple anterior abdominal wall hernia defects (e.g., one umbilical hernia and one incisional hernia), you will code one CPT for repair of all defects combined even if separate incisions are required. Because we have this rule of “one code per surgery” for any number of anterior abdominal wall hernia repairs, if some hernias are reducible and some are incarcerated during the same surgery, code the repair as incarcerated with a single CPT code (more on that below under item #4). Of note, parastomal, inguinal, femoral, and lumbar hernias are not subject to this rule and can be coded separately with their own CPT codes, when performed.
- Open vs. laparoscopic approaches are treated the same: We no longer have separate CPT codes for open vs. laparoscopic approach to hernia repairs. Each of the new codes includes the term “any approach” which means you may code them for anterior abdominal wall hernia repairs through open, laparoscopic, or robotic-assisted approaches.
- Mesh Insertion is Bunded: CPT 49568 has been deleted and mesh insertion is included in these new hernia repair codes “when performed.” This means there is no separate code for mesh placement for ventral and incisional hernia repairs which have historically permitted mesh insertion as an additional code. This also means that you report the same CPT code whether mesh is inserted or not.
- Total length of the hernia defect: This is perhaps the biggest change for hernia repair coding in 2023. You now code a single CPT for all anterior abdominal hernia repairs based on the total length of the defects. The CPT codes are written to report repairs of hernia defects that are less than 3 cm, 3 to 10 cm, or greater than 10 cm to reflect the different levels of surgical work required to repair these various hernias. Again, you report one code from CPT range 49591-49618 for the entire surgery regardless of the number of anterior abdominal wall hernia defects (more on that below under tips for accurate measurements).
Tips for Accurate Measurements:
- Measure the hernia defect before opening the fascial defect or from a preop CT scan. Once the tissue is incised, the fascia can retract, causing a defect to appear larger than is accurate. .
- The total length of the defect is taken as the maximum width or height if you drew an oval around the perimeter of the hernia defect.
- For swiss cheese defects (multiple defects separated by very small areas where the fascia is intact, giving the fascia the appearance of swiss cheese), measure from the superior (top) edge of the upper most defect to the inferior (bottom) edge of the lowest defect for the total length of repair.
- If there are multiple defects separated by 10 cm or greater of intact fascia, measure each defect individually and add the size of the defects together to report a single CPT code for the overall repair, but do not count the intervening intact fascia in the measurement. For example, if there is a supraumbilical defect measuring 3 cm and an incisional hernia along a prior Pfannenstiel incision measuring 6 cm, with 10 cm of intact fascia between them, the total defect size for coding purposes is 3 cm + 6 cm for a total of 9 cm (the 10 cm of intact fascia in between is not counted in the measurement).
- In contrast, when the defects are separated by less than 10 cm of intact fascia as in the swiss cheese defect example, the total measurement from the uppermost to the lowermost defect, inclusive of intact fascia, is counted. For example, if there is a 2 cm defect (defect 1), 3 cm of intact fascia, then another 2 cm defect (defect 2), 2 cm of intact fascia, and a final 2 cm defect (defect 3), your total measurement for coding purposes is 2 cm (first defect) + 3 cm (intact fascia between defect 1 and 2) + 2 cm (second defect) + 2 cm (intact fascia between defect 2 and 3) + 2 cm (third defect) for a total of 11 cm.
Again, this is probably the most substantial change to coding abdominal wall hernia repairs in 2023. Remember, if this is new for us as coders, it is new for our surgeons as well. Start working with your surgeons now to educate them about the importance of documenting the total length of the hernia defect and how to appropriately measure per the CPT guidelines.
6. Removal of Non-Infected Mesh: We now have a code for the removal of non-infected mesh (CPT 49623). This code was added to reflect the significant additional work of removing mesh which is not infected but may be plastered to the underlying abdominal tissues due to adhesions. CPT 49623 is an add on code that may be reported with any of the new hernia codes from range 49591-49622. Of note, infected mesh removal is still coded with CPT 11008 in 2023.
7. Parastomal Hernias: Parastomal hernia repairs are now coded with their own codes (CPT 49621-49622) and do not fall under the new anterior abdominal wall hernia repair codes. Parastomal hernias are also unique from other anterior abdominal wall hernia repairs in that the same code is reported for “initial or recurrent” hernias and the codes are only differentiated by reducible versus incarcerated hernias. Because parastomal hernias are now coded with their own series of codes, you can code for repair of an anterior abdominal wall hernia with one code (CPT codes 49591-49618) and repair of a parastomal hernia (49621-49622) with a second code during the same case if two distinct repairs are performed.
Note: These are the CPT guidelines for appropriate use of these codes. The NCCI edits and NCCI policy manual for 2023 have not been published yet. You should always check payer guidelines and edits before reporting two surgical codes together to ensure there are no bundling rules that deviate from CPT. If there are any substantive differences between the CPT guidelines and the NCCI guidelines on this topic, I will update this article once the NCCI guidelines are available (December 2022).
8. Global Days for New Codes: While this is not a CPT change, it is a change that will impact coding and billing of services out of the operating room, so it is worth mentioning. CMS has assigned a 000 global day indicator for these new hernia codes (CPT 49591-49622). Historically, hernia repairs were classified as major surgeries with 090 global day periods. This change from a 090 to 000 global period has a significant impact because you are now able to report postoperative services in the office separately where, before, they were considered part of a global surgical package.
So, those are the key changes and what to start preparing for in the new year. In December, I will write a follow up article with some additional coding examples to help you approach these new codes and guidelines with confidence.
