Author: Kimberly Mansingh

Today’s article is a continuation of our previous article about hernia repair coding. The goal of this article is to provide some examples of hernia repair notes and apply the method taught in the first article to determine how to code these examples. If you haven’t checked out the previous article, I encourage you to do so to gain the most benefit from the coding examples featured here: https://codingmastery.com/2018/07/28/hernia-repair-coding/.

Example #1:

Preoperative diagnosis: Incarcerated hernia
Postoperative diagnosis: Incarcerated hernia

Indications for procedure: Patient is a 44 year old female with a prior history of colectomy due to diverticulitis. Along the inferior
aspect of her previous midline incision, she noted a bulge that started 2 months ago. This morning she had a sudden onset of severe
abdominal pain and presented to the ER. Exam and CT scan revealed an incarcerated incisional hernia, and the patient was taken urgently to the OR.

Description of procedure:Patient was sterilely prepped and draped. A surgical time out was performed to confirm the appropriate patient and site for surgical incision. Using a 10-blade, an incision was made beginning at the superior aspect of the prior incision and carried down to the inferior aspect completely exposing the hernia defect. The hernia sac was entered, and incarcerated bowel and omentum were immediately observed. After lysing adhesions, the omentum and bowel were freed from the hernia sac and allowed to retract back into the abdomen. Bowel was inspected to ensure viability, and no areas of ischemia were noted. Therefore, we elected not to resect the bowel at this time.

We then resected the redundant tissues of the hernia sac and assessed our hernia defect. It was too large to repair primarily so we elected to place a piece of Vicryl mesh to ensure adequate repair. We tacked the mesh into place, and we confirmed complete closure of our defect and no injury to the underlying bowel. The tissues of the abdominal wall were then closed in layers beginning with the fascia followed by layered closure in the subcutaneous tissues, and the skin.

A hernia wrap was placed to ensure integrity of the abdominal wall and the patient was transferred to recovery in stable condition.

Let’s use the questions discussed in the previous article to break down the appropriate coding for this case. The items in italics from the note will be important for code selection.

Questions for Example #1:

1. What type of hernia is being repaired? We know from the pre and post operative diagnosis that the hernia is incarcerated but don’t know what type of hernia is present. When we read the indications for procedure we see the bulge which turns out to be a hernia on a CT scan is “at the inferior aspect of the prior incision” and the surgeon diagnoses an incarcerated incisional hernia.
2. Is the hernia reducible or incarcerated? Again if we look at the pre and postoperative diagnosis as well as the indications for  procedure, we see this is an “incarcerated” hernia. Additional details in the body of the operative report that confirm this hernia  is incarcerated include noting that “incarcerated bowel and ometum were observed” and then “freed from the hernia sac” (so these  incarcerated organs had to be surgically freed from the hernia).
3. What is the approach to the hernia repair? In the second sentence of the first paragraph of the description of the procedure, we see that the surgeon used a scalpel and made an incision along the prior incision from the colectomy mentioned in the                  indications for procedure and “carries that down….completely exposing the hernia defect.” So the surgeon is using an “incision”      and “directly visualizing the hernia defect” which makes this an open approach. 
4. Is this the initial hernia repair or a subsequent hernia repair in this same site? While the patient has had a prior surgery (a colectomy), there is no mention of a hernia in this same site along the incision line of the prior colectomy. Therefore, this is an initial hernia repair. 
5. Did the physician use mesh to repair the hernia? In the second paragraph of the report, we see the physician mention that the hernia defect is too large to repair primarily (which is another way of saying he cannot simply place sutures and repair the defect with sutures alone). So he “decides to place a piece of Vicryl mesh.” Therefore, this repair was performed with mesh.
6. How old is the patient? In this example, the patient is 44 years old (per the indications for procedure). The patient’s age will not affect our code based on the the type of hernia repair in this case, but there are some hernia repairs, especially open inguinal hernia repairs, that may be impacted by patient age. While this example includes the patient’s age in the note itself, the surgeon is not required to dictate the age of the patient specifically (you may pull that information from the patient’s date of birth in their demographics if the patient’s age is important to code selection).

Final coding for example #1: If we put the answers to our questions together we have an incisional hernia that is incarcerated. It is repaired through an open approach, this is the initial repair, and the physician uses mesh. The patient is 44 years old. Based on these details, our documentation supports the following codes:

CPT 49561: Repair initial incisional or ventral hernia; incarcerated. If we read the long description for this code in a software tool like Encoder Pro or a Coder’s Desk Reference we see that the physician “makes an incision” and “directly exposes the hernia defect” making this code appropriate for an open approach. The code description itself in CPT tells us this code is appropriate for an initial repair of an incisional hernia that is incarcerated.

CPT 49568: Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair). CPT 49568 is an “add on code.” It may never be reported by itself and must be reported in addition to a primary CPT code defined by the CPT guidelines. In the description we see this code is for implantation of mesh “for open incisional or ventral hernia repairs” (which fits our case) and that the guideline in parentheses tells us to “list separately in addition to code for the incisional or ventral hernia repair.” So we will report both CPT 49561 and 49568 in this example.

 

Example #2:

Preoperative diagnosis: LIH
Postoperative diagnosis: LIH

Procedure title: Laparoscopic repair of a left inguinal hernia

Indications for procedure: Patient is a 26 year old male who is an avid athlete and began experiencing pain in his
left groin 6 weeks ago. He presented as a consult from his primary care physician and was diagnosed with a left
inguinal hernia. Due to his young age, lack of any previous surgical history, and desire to return to his normal
activity level as quickly as possible, we discussed a laparoscopic repair. Risks and benefits were discussed with the patient,
and all of his questions answered. He presents today for elective repair.

Description of Procedure: After sterile prep and drape and a mandatory surgical time out, a small incision was made in the LLQ
and a port was placed. Additional ports were placed in the umbilical position and the RUQ. The abdomen was insufflated and the
scope was introduced. A survey of the abdomen was performed revealing no other pathology. The right groin was approached first
and no defect was noted. Then we approached the left groin where the hernia defect was immediately apparent. The hernia sac was excised confirming appropriate reduction. We then placed a small onlay mesh to ensure integrity of the repair given his young age and activity status. We tacked the mesh patch in place and confirmed successful repair of this defect. The abdomen was desufflated, ports were removed, and incisions were closed.

The patient was transferred to the recovery room in stable condition. He will follow up with me postoperatively in two weeks.
He was instructed to call right away if he had excessive drainage from the incision site, fever over 100 degrees Fahrenheit,
redness, excessive swelling, acute onset of pain, or any other signs of infection.

Questions for Example #2:

1. What type of hernia is being repaired? We know from the pre and post operative diagnosis that the hernia is an LIH (which an acronym meaning “left inguinal hernia”). In our particular example here, the surgeon goes on to tell us in the title of the report and the indications for procedure that this is a “left inguinal hernia” making the meaning of the acronym very clear, but this will not always be the case in operative reports you encounter on a daily basis. If you are unfamiliar with an acronym that appears in a report, use Google to do some research. A great acronymn website for medical abbreviations is Acronym Finder: https://acronymfinder.com/. This site allows you to type in an acronym and view potential meanings based on different contexts in which it may be used such as Science & Medicine or Military & Government.
2. Is the hernia reducible or incarcerated? If we look at our pre and postoperative diagnosis in this case, we know the type of hernia (inguinal) but not whether it is incarcerated or reducible. In the body of the report, the surgeon excises the hernia sac but does not note the presence of any incarcerated organs so this is a reducible hernia. Another clue that the hernia is likely not incarcerated is the fact the patient comes in for an elective repair per the indications for procedure (as opposed to an urgent/emergent repair we saw for the patient with an incarcerated hernia in example #1).
3. What is the approach to the hernia repair? In the title of the procedure, we see the word “laparoscopic.” Even if this word were missing, though, we have several clues in the body of the report that would allow us to determine the approach. In the first paragraph of the report, we see notations of “multiple small incisions,” “placing ports”, “insufflating the abdomen,” and introducing a scope, all of which point to a laparoscopic repair. In the last paragraph of the report,we see reversal of all these steps when the surgeon “desufflates the abdomen,” “removes the ports,” and “closes the incisions” (confirming this was a laparoscopic approach throughout the entire procedure).
4. Is this the initial hernia repair or a subsequent hernia repair in this same site? We see no mention of a prior hernia repair at this site, and the patient recently started having pain (about 6 weeks ago) so this is an initial repair.
5. Did the physician use mesh to repair the hernia? In the last paragraph of the report, we see the surgeon mention using an “onlay mesh” to ensure the repair is sufficient. Therefore, this repair was performed with mesh. Not all hernia repairs performed with mesh will allow us to separately report placement of the mesh, but we will break down this part of the repair in our final coding.
6. How old is the patient? In this example, the patient is 26 years old (per the indications for procedure). Again, the patient’s age will not always affect the code, and the surgeon is not required to dictate the age of the patient specifically (you may pull that information from the patient’s date of birth in their demographics if the patient’s age is important to code selection).

Final coding for example #2: If we put the answers to our questions together we have an inguinal hernia that is reducible. It is repaired through a laparoscopic approach, this is the initial repair, and the physician uses mesh. The patient is 26 years old. Based on these details, our documentation supports the following code:

CPT 49650: Laparoscopy surgical; repair, initial inguinal hernia. We see from the CPT description that this code is appropriate for a laparoscopic approach for an inguinal hernia and for an initial repair. Notice that the concept of reducible or incarcerated and the patient’s age is not addressed in the laparoscopic CPT codes for inguinal hernias. If the procedure was significantly complicated by the patient’s young age requiring the surgeon to work in a smaller space or by incarcerated organs that needed to be reduced, you could consider adding a modifier 22 since there are no dedicated codes to represent these variables when it comes to laparoscopic hernia repairs.

Mesh placement: While the surgeon placed mesh to repair the hernia, the CPT guidelines state that with the exception of open incisional or ventral hernia repairs (49560-49566), the insertion of mesh or other prosthesis is not separately reportable. Therefore, we cannot report CPT 49568 for insertion of mesh like we could in the first example. The mesh placement is considered included in CPT 49650.

Using this method to break down your hernia repair notes will help you pick accurate codes with each case.

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: Continue reading “Hernia Repair Coding” →