Hernia Repair – Code it Right to Maximize Reimbursement

by | Published on Mar 1, 2017 | Medical Coding

Hernia Repair
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General surgery medical coding services ensure comprehensive documentation support for a wide variety of procedures. One of the common conditions that general surgeons treat is umbilical hernia.

There are two approaches to surgical hernia repair: open surgical repair and laparoscopic surgery. Both these methods involve using a piece of synthetic or prosthetic mesh to support the abdominal wall. In open surgical repair, an incision is made directly over the hernia defect and the prosthetic mesh is sewn to the abdominal wall. The minimally invasive or laparoscopic approach involves placing the mesh prosthesis through a cannula and using staples and stitches to fix it to the undersurface of the abdominal wall. There are unique medical billing codes for various types of hernia repair.

Primary hernias

Hernias are classified as reducible, irreducible, obstructed or strangulated. Usually, general surgeons repair primary hernias and a plastic surgeon’s services are not required. The following CPT codes are used to report hernia repair:

49505 – Repair initial inguinal hernia > 5 yrs. or over, reducible, under 5 years
49560 – Repair initial incisional or ventral hernia; reducible
49561 – Repair initial incisional or ventral hernia; incarcerated or strangulated
49585 – Repair umbilical hernia, age 5 or older; reducible
49587 – Repair umbilical hernia, age 5 or older; incarcerated or strangulated

Code 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; 49568 is never reported alone and does not take “modifier 51 multiple procedures”. Therefore, repair of the repair of a primary reducible incisional hernia that requires the use of a mesh is reported as follows:
49560 Herniorrhaphy, primary, reducible
49568 Implantation of mesh

Points to note:

  • These CPT procedures have a 90-day global period
  • Mesh placement is billable only for ventral and incisional hernia
  • Code 49568 should be listed separately in addition to code for the incisional or ventral hernia repair
  • The appropriate proper location/site modifier can be used whenever it is applicable (for instance, LT for Left Side and RT for Right Side)

Recurrent hernias

Repair of recurrent hernias are usually complex and a plastic surgeon may be also involved to address attenuated or absent tissues. The procedure codes for recurrent hernia are:

  • 49565 Repair recurrent incisional or ventral hernia; reducible
    Add-on code 49568 is reported along with 49565 if synthetic mesh is used.

A complex procedure such as the repair of a recurrent, incarcerated hernia is coded as follows:

  • 43566 Herniorrhaphy, recurrent, incarcerated

Use of nerve block anesthesia

For inguinal hernia repair (CPT code 49505), the surgeon may use an ilioinguinal or iliohypogastric nerve block (CPT 64425). In this case, the nerve block is not reported separately and is included in the surgical procedure. So, 64425 is bundled into 49505.

Laparoscopic Surgical Hernia Repair

Laparoscopic epigastric and hiatal hernia repair is coded as follows:

  • 49652 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible
  • 49653 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated
  • 43281 Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh
  • 43282 Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh

Similarly, there are separate codes for laparoscopic incisional hernia repair, laparoscopic inguinal hernia repair, laparoscopic Spigelian hernia repair, laparoscopic umbilical hernia repair, laparoscopic ventral hernia repair, epigastric hernia repair, femoral Hernia Repair, and hiatal hernia repair.

Summary of considerations when coding for hernia repair

  • Location of the hernia – epigastric, hiatal, inguinal, incisional, femoral, ventral, and so on
  • Patient’s age – younger than 5 years old/older than 5 years old
  • Surgical method – open surgery or laparoscopic
  • Primary or recurrent hernia
  • Whether hernia is incarcerated or strangulated
  • If mesh placement was involved

General surgery medical billing and coding companies have AAPC-certified coders who are up to date on the latest CPT and ICD-10 codes for various surgical procedures. Partnering with a reliable company is the best strategy for general surgeons to ensure accurate coding of simple and complex procedures for proper claim submission and reimbursement.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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