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Cord Lipoma and Abdominal Mass Excisions Integral to Inguinal Hernia Repair?

Camille Posted Thu 12th of December, 2019 14:46:22 PM
QUESTION: I interpret this Op Note indicates that the both the abdominal lipomatosis mass and the sperm cord lipoma excisions are both integral to the laparoscopic inguinal hernia repair and therefore not separately billable. Do you agree? Thank you kindly!***************************** "PREOPERATIVE DIAGNOSIS: Right inguinal hernia. POSTOPERATIVE DIAGNOSIS: Right inguinal hernia, cord lipoma. PROCEDURE: Laparoscopic right inguinal hernia repair with mesh, TEP, laparoscopic cord lipectomy, laparoscopic lipectomy. A transverse infraumbilical incision was made through the skin and carried down to the fascia. The fascia was incised to the right of midline through the anterior sheath only. The rectus muscle was retracted anteriorly, exposing the posterior sheath. A large 12 mm spoon grasper was passed blindly to the pubic bone and careful blunt dissection was performed to establish enough room for trocar placement. A 12 mm balloon trocar was then inserted and 12 mmHg of pneumoextraperitoneum was established. Two additional 5 mm trocars were inserted in the suprapubic midline under direct laparoscopic visualization without complication. First, I attempted to establish the medial dissection. However, there was a large lipomatosis mass hanging from the anterior surface. This was dissected and noted to be enveloping the epigastric vessels. It was completely resected using cautery. It did apparently go out a very superficial direct-appearing defect. This was not connected to the bladder. This lipoma was completely excised and removed. The Cooper's ligament and pubic bone were then dissected clear. The lateral dissection was then performed out to the space of Bogros near the anterosuperior iliac spine. The peritoneum was tracked back to a moderate-sized indirect inguinal hernia. The cord structures were skeletonized. In doing this, a moderate-sized right cord lipoma was also excised. The peritoneum was dissected free from the cord structures and dissected back to the level where the vas deferens and cord vessels diverged. The psoas muscle was easily identified. The medial and lateral dissections were then connected, allowing good mesh placement. Having the entire myopectineal orifice well exposed, a piece of Bard 3DMax large right mesh was inserted. The mesh was overlapped at the midline. There was 3 cm of posterior coverage of Cooper's ligament. The mesh was set between the myopectineal orifice and the peritoneum. Insufflation was then reduced under direct laparoscopic visualization and the mesh did not roll, fold, or twist. All trocars were removed and the pneumoperitoneum was reduced."
SuperCoder Answered Fri 13th of December, 2019 02:43:17 AM

Hi Camille,

AAE does not provide coding/review for operative reports and chart notes.

SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding/review of an operative report or chart note, which might charge you more. You can contact (866)228-9252 or e-mail customerservice@supercoder.com for further information.

In general, when performing the big procedure and some minor procedure are performed around the same anatomical locations, usually small procedures are bundled into the major procedure. Otherwise, modifier 22 (Increased Procedural Services) can be appended with the primary procedure.

In order to append modifier 22 to a surgical procedure, check that the physician documented the reason(s) why the work he performed was more than he typically performs, and the documentation should include any or all of the following:

  • Increased intensity
  • Additional time
  • Technical difficulty
  • Severe patient condition, which causes the surgery to be difficult, dangerous to the patient, and requires additional physical and mental effort from the physician

An unusual procedure is not when the physician took only a few extra minutes on the patient’s case or when the physician documents that the procedure was only slightly more difficult. There is an average range of difficulty for every procedure. A procedure could be slightly more difficult and still meet the definition of the procedure and not warrant appending modifier 22.

Hope this helps!

Camille Posted Fri 13th of December, 2019 14:00:04 PM
Apologies. I often include the note for perspective and to save time-as you have occasionally requested more information in past inquiries. I should have reduced the note to just the small portion i was questioning. Please allow me to rephrase my question: Would it ever be appropriate to bill a subcutaneous lipoma excision when it is within an excision performed for a greater procedure? I believe not, but my provider would like your expert opinion. Thank you very much.
Camille Posted Sun 15th of December, 2019 12:46:18 PM
Would it ever be appropriate to bill a subcutaneous lipoma excision when it is found within the excision performed for a greater procedure? I believe not, but my provider would like your expert opinion. Thank you very much.
SuperCoder Answered Wed 18th of December, 2019 04:38:17 AM

Hi Camille,

Hope you are doing good.

Yes, you are on the right path. As described earlier, when big procedure has been performed and some minor procedure(s) also performed around the same anatomical locations, usually small procedures are bundled into the major procedure. When abdominal lipomatosis mass and the sperm cord lipoma excisions has been performed with the inguinal hernia repair, most likely lipoma excision would be bundled with the primary procedure.

Since increased intensity and additional time is applicable, it is suggested to append modifier 22 (Increased Procedural Services) with the primary procedure.

On the op-note: Some time we require more information to clarify the procedure, but AAE does not provide coding/review for operative reports and chart notes.

Hope this helps!

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