There are many different hernia repair procedures, and using the correct CPT and diagnosis codes when billing for such services can be quite complicated for surgeons and their office staff. But once they understand the correct codes, practices can receive proper reimbursement.
Is it Ventral, Epigastric or Umbilical?
It is common for the surgeon to submit the following documentation in the op report about a hernia repair to his office staff:
1. Preoperative diagnosis: Epigastric hernia
2. Postoperative diagnosis: Epigastric hernia
3. Procedure: Repair of ventral
hernia with insertion of marlex mesh
For the surgeon, there is no conflict between the pre- and postoperative diagnoses and the procedure because, clinically speaking, a ventral hernia is defined as any hernia of the abdominal wall other than one that is inguinal or femoral. Using this definition, the procedure qualifies as a ventral hernia, even though the documentation for both pre- and postop diagnoses clearly states otherwise. (For more information on hernia, see box on page 27.)
But for billing, such a report poses significant problems for the coder, beginning with the fact that CPT 1999 specifically differentiates among a number of herniae repair that could clinically be defined as ventral, listing more than 20 specific abdominal wall hernia repair procedure codes. Furthermore, Medicare has assigned varying relative value units (RVUs) to the procedures, which makes it even more important to use the right code so you can be paid correctly.
It would be very easy to code all abdominal herniae other than inguinal or femoral with ventral hernia codes (49560-49566; for definition, see box on page 27) based on the clinical definition, but the codes need to be based solely on the documentation in the operative report, says Kathleen Mueller, RN, CPC, CCS-P, a registered nurse and reimbursement and coding specialist in the office of Allan L. Liefer, MD, a general surgeon in Chester, IL. The operative report referred to above, Mueller says, clearly indicates that the procedure should be coded as an epigastric hernia (49570-49572), since the diagnosis code of epigastric hernia would not match the repair of ventral hernia.
Billing for Mesh Application
1. Insertion: The insertion of the marlex mesh poses another problem, says Stephanie Albright, CPC, CPC-H, a general surgery coding specialist
with Coding Strategies Inc. of Dallas, GA. She notes that 49568 (implantation of mesh or other prosthesis for incisional or ventral hernia repair [list separately in addition to code for the incisional or ventral hernia repair]) clearly states the procedure is an add-on code that can be listed only for ventral, or incisional, hernia procedures. If, however, the surgeon repairs an epigastric or umbilical hernia, mesh implantation cannot be billed separately, because it [...]