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Annette Posted Mon 13th of December, 2010 02:40:02 AM

I'm new at hernia repair coding and quite confused with these!   Is the following reducible inguinal hernia repair or incarcerated?

Direct inguinal hernia found. 

The ilioinguinal nerve that was directly in the field was transected high. With this having been completed a plane beneath the external oblique identifying the conjoint tendon and the inguinal ligament and somewhat above superiorly was created. With this having been completed the direct sac was identified. It was mobilized circumferentially and a pro peritoneal dissection space created using gauze and gentle blunt finger dissection. A modified kugel system circular pro peritoneal patch was inserted into the pro peritoneal space and spread out. The two tails were cut short anchored to the conjoint tendon medially into the inguinal ligament laterally. An onlay patch was then selected. It was placed over the inguinal floor anchored to the pubic tubercle area, the conjoint tendon, and the inguinal ligament with interrupted 2-0 vicryl sutures. At the internal ring area the mesh was incised and teed in standard fashion and wrapped around the cord suturing to itself again using 2-0 vicryl and then to the inguinal ligament. The upper portion of the mesh was placed beneath the external oblique.  Then the pubic tubercle, inguinal ligament, conjoint tendon, and the eminence for the ilioinguinal and iliohypogastric nerves were infiltrated with .025% Marcaine. External oblique & subcutaneous tissue was then closed.

My second question is, I've been told that an incarcerated hernia cannot be reduced but I think that is not true?

Thank you

SuperCoder Answered Mon 13th of December, 2010 05:19:16 AM

This is common to both type of repair: The physician makes a groin incision. The hernia sac is identified and dissected free from surrounding structures. The hernia sac is ligated and resected. The groin incision is closed.

The difference with incarcerated inguinal hernia is the trapping of abdominal contents within the Hernia itself. The BULGE CAN NOT BE REDUCED or pushed back. This could mean that intestine from within the abdomen is trapped in the hernia and the risk of injury to abdominal contents and intestine is increased. Surgical release and hernia repair are emergently necessary to avoid injury to the intestine.

This is the reason why in incarcerated inguinal hernia repair, the sac is opened and the contents of the sac are examined. IF the CONTENTS OF THE HERNIA ARE VIABLE, THE HERNIA IS REDUCED. So, an incarcerated hernia whether reducible or not can be known only after opening and examining the hernia sac.

In case of reducible inguinal hernia, there will be no documentation of opening the hernial sac (for examination to know the viability of reducing it), then that means it is identified as reducible and there is no entrapment of abdominal contents. This is what you can observe in the given report, which I suggest to be reducible and not incarcerated.

Annette Posted Mon 13th of December, 2010 16:37:21 PM

okay.. so I want to make sure I'm understanding this... I have another report that states, Patient has an "incarcerated inguinal hernia" but the hernia was reduced, so this is possible as long as the contents of the sac are examined, and contents were viable and reduced? I can then use CPT 49505?

Thank you so much for your help :-)

SuperCoder Answered Mon 13th of December, 2010 19:31:38 PM

When it is not mentioned in the report of what type Inguinal hernia it is, we should apply the concept.

Otherwise, if it is documented as "Incarcerated Inguinal Hernia", then we would code for the same, even if it is reduced. Reasons:

a. because of the reason that "Incarcerated Inguinal Hernia" can not be reduced unless the sac is opened, so obviously the procedure is extensive than only reducible inguinal hernia repair.

b. as the procedure performed is definitely extensive than Only Reducible hernia repair and also logically the Fee value for Incarcerated inguinal hernia is higer than Reducible inguinal hernia.

Annette Posted Mon 13th of December, 2010 19:56:47 PM

I'm so sorry but Im a bit confused....For example I have an op report.. that states ....incarcerated inguinal hernia repair,.... & the following was mentioned on report: Thanks alot for your time!

"Repair of right incarcerated inguinal hernia with mesh with Reduction & omentectomy"

With the spermatic cord and its elements were gently surrounded with Penrose drain and ertracted inferiorly, We now gently with counter pressure on the scrotum reduced this large pantaloon type hernia into the groin. We then opened the sac and find it is filled with omentum. With the sac opened a little larger, we were able to pull the whole omentum up out of the sac and button hole it multiple times taking it between clamps and dividing between the clamps and excising this large quantity of omentum. Remaining clamps were tied off with 2-0 vicryl and then we are able to reduce the small amount of remaining omentum back into the abdomen. The sac was then purse string closed and that suture was tied and this was done with o-ethibond and remaining sac was excised with cautery and t hen we oversewed the sac imbricating the remaining tied off the portion underneath the transversalis fascia with interrupted figure of eight 0-ethibond. With this done, the groin floor was now inspected. we placed a keyhole mesh that was soaked in antibiotic saline into the groin.

SuperCoder Answered Tue 14th of December, 2010 16:21:45 PM

Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated : 49507 (16.55 RVU)
Omentectomy, epiploectomy, resection of omentum (separate procedure) : 49255 (20.62 RVU)

CCI edits says, Code 49255 is a column 2 code for 49507, These cannot be billed together in any circumstances.

Going by Coding guidelines, we should code only 49507. But, as this is going to affect the provider, so need to collect info on Payor preference this case.
Other than payor preference, the best option is: 49507-22, because of the extra efforts involved in Omentectomy. We need to keep in mind to bill it mentioning the reason why modifier 22 being used in a letter while filing (on paper if denied.)

Annette Posted Tue 14th of December, 2010 20:03:40 PM

Ok. Will do. Thanks again. You were really helpful.

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