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Charlene Posted Fri 22nd of March, 2019 10:44:19 AM
Pt is s/p spine surgery through flank. There was a significant bulge and discomfort in this area. The CT scan indicated hernia. At surgery hernia was not found, but muscle weakness and bulging due to denervation. The inferior & superior area of the muscle and fascia was closed by plication with multiple sutures in a horizontal row. This is the only procedure performed. If an unlisted code is suggested, please provide another cpt to compare with.
SuperCoder Answered Mon 25th of March, 2019 05:30:18 AM

You are correct, there is no specific code available for the described procedure, but unlisted code.

Since, repair of muscle and fascia is usually the part of hernia repair, so it is suggested to provide the comparison code from the code range of specific area from which you planned the hernia repair. As in, if you planned the ventral hernia, then provide the comparison code 49560 or 49561. In the procedure 49560 (Repair initial incisional or ventral hernia; reducible), the provider makes an incision to access the hernia. He dissects down through scar tissues, removing adhesions as needed and identifying the hernia sac. The provider reduces the hernia sac, pushing it back into proper anatomic position, and repairs the defect with sutures. The provider checks for bleeding, removes any instruments, and finally closes the incision.

Likewise, you can select the repair comparison code according to the diagnosis of the patient, eg., inguinal hernia (according to the patient's age, code range; 49491-49525), lumbar hernia (49540), femoral hernia (49550-49557), ventral hernia (49560-49566). On the other hand, if the procedure is performed laparoscopically, then use the comparison code from the code range 49650-49659, according to the patient's medical condition.

Also, when reporting a procedure with an unlisted code, submit a cover letter explaining the reason for choosing the unlisted code instead of a defined, active code. Also include the operative notes or other relevant documentation to strengthen the claim and to avoid a possible denial. Your payers will consider claims with unlisted procedure codes on a case by case basis, and they will determine payment based on the documentation you provide.

Hope this helps!

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