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Is 49321 billable w/ a hernia repair

Stephanie Posted Tue 14th of January, 2020 16:14:12 PM
Hello, I would like to ask for clarification regarding information in the CCI manual Chpt 6, Section H, Paragraph 3; If a biopsy is performed and submitted for pathologic evaluation that will be completed after the more extensive procedure is performed, the biopsy is not separately reportable with the more extensive procedure. The case in question had two different type of hernias repaired an Open Umbilical hernia repair 49587 and a Laparoscopic bilateral inguinal hernia repairs 49650-50. A recent audit stated because the tumor was involved with the hernia sac, it is not separately reportable. per the note "On the very tip of the hernia sac, there was involvement of tumor and this required sharp dissection." The tumor was involved w/ the Lt inguinal hernia and the operative note does not indicate a specimen from this location going to pathology, only the nodule and the umbilical hernia sac. In this case would I be able to bill for the bx of the tumor under 49321 or would it still be considered bundled?
SuperCoder Answered Wed 15th of January, 2020 02:40:27 AM

Hi Stephanie,

 

Although you may not separately report (or receive reimbursement for) a biopsy following a more extensive procedure, such as an excision, at the same anatomic location and patient encounter, you may report the biopsy separately if it precedes and leads to the more extensive procedure.

 

If the biopsy is performed on the same lesion on which a more extensive procedure is performed, it is separately reportable only if the biopsy is utilized for immediate pathologic diagnosis prior to the more extensive procedure, and the decision to proceed with the more extensive procedure is based on the diagnosis established by the pathologic examination. The biopsy is not separately reportable if the pathologic examination at the time of surgery is for the purpose of assessing margins of resection or verifying resectability.

 

The Policy Manual further asserts, “If a biopsy is performed and submitted for pathologic evaluation that will be completed after the more extensive procedure is performed, the biopsy is not separately reportable with the more extensive procedure.”

 

In other words: If a biopsy at the same anatomic location/patient encounter precedes a more extensive procedure (such as an excision, destruction, or removal), you may report both procedures. If the more extensive procedure precedes the biopsy, do not report the biopsy separately.

 

Please find below AAPC blog for more information:

 

https://www.aapc.com/blog/27807-coding-for-biopsy-with-a-related-more-extensive-procedure/

 

Thanks!

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