A hernia occurs when an internal organ or other body part protrudes through the wall of muscle or tissue that normally contains it. Most hernias occur within the abdominal cavity, between the chest and the hips.
Types of hernia:
Inguinal hernia: It occurs when tissue pushes through a weak spot in the groin muscle.
Femoral hernia: It occurs when tissue bulges from the lower belly into the upper thigh, just below the groin crease.
Umbilical hernia: It occurs when intestine, fat or fluid pushes through a weak spot in the belly.
Incisional hernia: It occurs after surgery in the belly region.
Epigastric hernia: It occurs in the middle of the belly between the breastbone and the belly button or navel.
Hiatal hernia: It is different from other types of hernia as it involves the stomach instead of the intestine. It occurs when part of your stomach bulges up through your diaphragm and into your chest.
From coding perspective, you need to determine the following factors for appropriate code selection:
- Identify the type of hernia – inguinal, umbilical and so on.
- Identify patient’ age – Not all hernia repair codes are age specific. Example of age specific hernia repairs include inguinal hernia repair. However, femoral hernia repair codes are not age specific.
- Surgical method – Open versus laparoscopic method
- Identify whether it is initial or recurrent – Based on whether the hernia has undergone any previous repair.
- Identify the clinical presentation as reducible, incarcerated or strangulated.
- Identify any mesh placement was involved in the repair.
An example of inguinal hernia repair code is given below to illustrate the identifying factors in the code description.
49505 – Repair initial inguinal hernia, age 5 years or older; reducible
- Identify the type of hernia – Inguinal hernia
- Identify patient’ age – Age 5 years or older
- Surgical method – Open repair
- Identify whether it is initial or recurrent – Initial hernia repair
- Identify the clinical presentation – reducible
- Identify any mesh placement was involved in the repair – Mesh placement is included in the inguinal hernia repair code. Therefore additional code for mesh placement is not required.
The major classification of Hernia repair codes based on the surgical approach is as below:
Inguinal: 49491 – 49525
Lumbar hernia: 49540
Femoral: 49550 – 49557
Incisional/ventral hernia: 49560 – 49566
Umbilical hernia: 49580 – 49587
Hiatal hernia: 43332 – 43337
Inguinal: 49650 – 49651
Ventral/umbilical/epigastric: 49652 – 49653
Incisional hernia: 49654 – 49657
Hernia repair codes 49491-49651 are described as unilateral procedures. Therefore if performed as a bilateral procedure, then you need to append modifier 50 – Bilateral procedure to the appropriate CPT code. If hernia repair is unilateral, then you need to append modifier RT or LT to indicate the anatomic site of the procedure performed.
As hernias have a high rate of recurrence, surgeons often use surgical mesh to strengthen the hernia repair and reduce the rate of recurrence. The use of mesh or other prosthesis is considered inherent to all laparoscopic hernia repairs (49650-49657) and to some of the open hernia repair codes, including inguinal (49491–49525), lumbar (49540), femoral (49550–49557), epigastric (49570–49572), umbilical (49580–49587), and spigelian (49590). Therefore, you do not report separately for the mesh placement if it is performed during these repairs.
However, the mesh placement is not inherent to the open repair of incisional or ventral hernias (49560-49566). Therefore, you can report the add-on code +49568 if the mesh is placed during the incisional or ventral hernia repairs.
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)
The mesh removal can be done at the following circumstances:
Removal of implanted mesh along with recurrent hernia repair:
If recurrent hernia repair is done with removal of implanted mesh from a previous surgery, then the removal of mesh is included in the recurrent hernia repair codes and should not be coded separately. However, if extensive time is required to dissect the old mesh, the appropriate reimbursement can be achieved by adding modifier 22-increased procedural service to the recurrent hernia repair codes.
Removal of mesh that is infected:
For removal of mesh that is infected or involved in an enterocutaneous fistula, report code 11008, Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary procedure). This add-on code must be reported with either 10180 or 11004-11006 as appropriate.
Removal of mesh that is non-infected:
If implanted mesh from previous surgery is removed without any recurrent hernial repair, then it is appropriate to code the mesh removal separately. However, there is no separate code of implanted mesh removal and therefore the service can be reported with unlisted procedure code 49999 Unlisted procedure, abdomen, peritoneum and omentum.