Author: Kimberly Mansingh

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

Q. A patient had a total hip arthroplasty last year, but due to infection, the prior total hip (both acetabular and femoral components) had to be removed. In their place, the surgeon inserted a static antibiotic spacer. The patient now presents four months later after the infection resolved and is ready for a new total hip. How are the removal of the antibiotic spacer and the insertion of the new total hip (again both acetabular and femoral components) coded?

A. Assign CPT 27132: Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft. This code will include the removal of the spacer, the insertion of a new total hip (both acetabular and femoral components), and any bone grafting that may be necessary (note that bone grafting is not required but it is included when performed).

Coding Tips: While you may be tempted to code CPT 27134: Revision of a total hip arthroplasty, both components, with or without autograft or allograft instead since the patient had a total hip arthroplasty in the past, it’s important to note that this code represents removal of a total hip with insertion of a new total hip during the same operative session. In a case where the patient already had the original total hip removed in an earlier surgery and was left with a static antibiotic spacer, code 27134 would not be accurate since there are no total hip components to remove.

Articulating vs. Static Spacers: It’s also important to understand that antibiotic spacers can be static or articulating. Static spacers such as the one featured in the question above are inserted to resolve infection after the infected joint prosthesis is removed and provide no mobility for the joint. Articulating spacers on the other hand are specialized antibiotic spacers that contain a femoral stem and a modular head that allows for some mobility of the hip while the infection is resolving. Articulating spacers reduce the risk of joint contracture because of immobility in the joint and may be used for patients who have a prolonged infection that must be resolved before the new total hip can be inserted.

In an operative report that describes removal of an articulating spacer followed by insertion of a new total hip, you might see language that reads “we then turned our attention to the femoral stem” or “the femoral component was then removed.” This can be confusing because a permanent hip prosthesis also has a femoral component (sometimes referred to as a femoral stem). Seeing this language may lead a coder to conclude that the patient still had one of the permanent components from the original total hip in place and create confusion around whether to code 27132 or perhaps 27134 or even 27138. With that said, we would not expect to see a patient with a component of a permanent hip prosthesis and an antibiotic spacer at the same time so that referral to a “femoral stem” or a “femoral component” is generally just part of an articulating spacer (which is a temporary implant not a permanent prosthesis).

Coding Caveat? Until this year, the guidance for coding removal of a static or an articulating spacer followed by insertion of a new total hip has been the same: report CPT 27132. At the AMA Symposium in late 2019, though, the American Academy of Orthopedic Surgery (AAOS) outlined some new proposed guidance for coding this type of two-stage joint replacement when an articulating spacer is involved. Instead of recommending 27132 for removal of the articulating spacer followed by insertion of a new total hip, the AAOS suggested reporting 27134 instead because the work of removing an articulating spacer is similar to that of removing the original permanent hip prosthesis. While I certainly agree with that thought, I have not seen new guidance from the AMA or CMS supporting this new recommendation just yet. Typically, once authoritative guidance from these agencies is published, insurance carriers will align with the new guidance, making it easier to get your claims paid following the new rules. So for now, I continue to use the 27132 following the historical guidance (adding modifier 22 for increased complexity associated with removal of an articulating spacer when supported by the documentation). I am also keeping an eye out for any references from these agencies that aligns with the AAOS recommendation to report CPT 27134 for a surgery where an articulating spacer is removed and a new total hip is inserted and will update this article once such guidance is received. In the interim, I would encourage you to discuss this surgery with your top payers and your internal team at your organization to ensure accurate and optimal coding.

References: CPT Assistant, December 1, 2008, copyright American Medical Association

International Journal of Medical Sciences, copyright Ivyspring International Publisher (source for overview of static vs. articulating spacers) Static vs. Articulating Spacers